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THE  TREATMENT 


OF 


FRACTURES 


BY 

CHARLES  LOCKE  SCUDDER,  M.D. 

SURGEON   TO    THE  MASSACHUSETTS    GENERAL    HOSPITAL,   OUT-PATIENT   DEPARTMENT: 

ASSISTANT  IN   CLINICAL  AND  OPERATIVE  SURGERY  IN   THE    HARVARD 

UNIVERSITY   MEDICAL  SCHOOL. 


ASSISTED  BY 

FREDERIC  J.  COTTON,  M.D. 


SECOND     EDITION,     REVISED 


■Mith  6\\  1f llustrattons 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    &    COMPANY 
190 1 


'01 


Copyright,  1901,  by  W.  B.  Saunders  &  Company 


Registered  \i  Stationers'  Hall,  London,  England 


s 


on 


02 
a. 


TO 


ARTHUR  TRACY  CABOT,  A.M.,  M.D. 


PREFACE  TO  THE  SECOND  EDITION 


In  this  edition  many  X-ray  plates  have  been  reproduced  to 
assist  in  familiarizing  the  reader  with  the  interpretation  of  such 
plates.  Physicians  should  be  able  to  interpret  X-ray  plates 
without  the  assistance  of  an  expert. 

A  series  of  clinical  cases  has  been  introduced  to  render  more 
helpful  the  chapter  upon  Skull  Fractures.  Numerous  illustra- 
tions have  been  added  to  the  chapter  upon  Plaster-of-Paris. 
Emphasis  is  laid  upon  the  use  of  plaster-of-Paris  in  the  treat- 
ment of  almost  every  fracture.  The  Index  has  been  made  more 
serviceable. 

Through  the  kindness  and  liberality  of  the  publishers  the 
addition  of  new  illustrations   has  enhanced  the  practical  value 

of  the  book. 

Charles  L.   Scudder 
1S9  Beacon  Street,  Boston,  Mass. 
January,  igoi 


PREFACE  TO  THE  FIRST  EDITION 


The  general  employment  of  anesthesia  in  the  examination 
and  the  initial  treatment  of  fractures,  especially  of  those  near  or 
involving  joints,  has  made  diagnosis  more  accurate  and  treat- 
ment more  intelligent.  The  application  of  the  Rontgen  ray  to 
the  diagnosis  of  fracture  of  bone  has  already  contributed  much 
toward  an  accurate  interpretation  of  the  physical  signs  of  frac- 
ture. This  greater  certainty  in  diagnosis  has  suggested  more 
direct  and  simpler  methods  of  treatment.  Antisepsis  has  opened 
to  operative  surgery  a  very  profitable  field  in  the  treatment  of 
fractures.  The  final  results  after  the  open  incision  of  closed 
fractures  emphasize  the  fact  that  anesthesia,  antisepsis,  and  the 
Rontgen  ray  are  making  the  knowledge  of  fractures  more  exact, 
and  their  treatment  less  complicated.  The  attention  of  the  stu- 
dent is  diverted  from  theories  and  apparatus  to  the  actual  condi- 
tions that  exist  in  the  fractured  bone,  and  he  is  encouraged  to 
determine  for  himself  how  to  meet  the  conditions  found  in  each 
individual  case  of  fracture. 

This  book  is  intended  to  serve  as  a  guide  to  the  practitioner 
and  student  in  the  treatment  of  fractures  of  bone.  In  the  follow- 
ing pages  many  of  the  details  in  the  treatment  of  fractures  are 
described.  So  far  as  possible  these  details  are  illustrated.  A 
rwv  very  unusual  fractures  are  omitted.  Mechanical  simplicity 
is  advocated.  Splints  of  special  manufacture  are  not  described, 
as  their  use  distracts  attention  from  the  fracture.  An  exact 
knowledge  of  anatomy  combined  with  accurate  observation  is 
recognized  as  the  proper  basis  for  the  diagnosis  and  treatment 
of  fractures.  The  expressions  "  closed  "  and  "  open  "  fracture 
are    used    in    place    of   "simple"    and    "compound"    fracture. 


12  PREFACE 

"Closed"  and  "open"  express  definite  conditions,  referring-  to 
the  freedom  from,  or  liability  to,  bacterial  infection.  The  old 
expressions  are  misleading  despite  their  long  usage.  Theories 
of  treatment  are  not  discussed.  Types  of  dressings  for  special 
fractures  are  described.  Many  illustrative  clinical  cases  are 
omitted  purposely. 

The  tracings  of  the  Rontgen  rays,  which  have  been  very 
generally  used  to  illustrate  the  sites  and  the  displacements  ot 
fractures,  have  been  the  subject  of  careful  study.  Each  tracing 
represents  the  combined  interpretation  of  the  plate  made  by 
skilled  observers  who  were  in  every  instance  familiar  with  the 
clinical  aspects  of  the  case.  The  writings  of  many  who  have 
contributed  their  experience  to  the  literature  of  fractures  have 
been  consulted.  Those  to  whom  I  feel  indebted  for  suggestions 
are  mentioned  in  the  section  on  Bibliography.  References  to 
literature  are  not  made  in  the  text. 

I  take  this  opportunity  to  extend  my  thanks  to  the  members 
of  the  Surgical  Staff  of  the  Massachusetts  General  Hospital  for 
their  courtesy  in  permitting  me  to  study  cases  of  fracture  of  the 
lower  extremity  in  the  wards  of  the  hospital,  and  to  Professor 
Thomas  Dwight  for  the  use  of  valuable  anatomical  material.  I 
also  thank  Dr.  F.  J.  Cotton  for  an  untiring  interest  in  the  pro- 
duction of  most  of  the  drawings,  and  in  the  search  for  fracture 
literature.  The  half-tones  are  made  from  photographs  taken 
under  the  direct  superintendence  of  the  author.  Due  credit  for 
illustrations  not  original  is  given  next  the  legend. 

I  wish  to  thank  Mr.  Walter  Dodd  for  his  courtesy  and  inter- 
est connected  with  the  production  of  the  Rontgen-ray  plates, 
and  Dr.  H.  P.  Mosher  for  kind  assistance. 

The  chapter  on  the  Rontgen  ray  is  written  by  Dr.  E.  A. 
Codman. 

Charles  L.  Scuddek 
189  Beacon  Street,  Boston,  Mass. 

April,  /goo 


TABLE  OF  CONTENTS 


CHAPTER  I  PAC1! 

Fractures  of  the  Skull 17 

Fractures  of  the  Vault 22 

Fractures  of  the  Base 24 

Treatment 34 

Pistol  Shot  Wounds  of  the  Skull 37 

Later  Results  of  Fracture  of  the  Skull 38 

CHAPTER    II 

Fractures  of  the  Nasal  Bones 44 

The  Nasal  Septum 47 

Treatment 49 

Fractures  of  the  Malar  Bone 52 

Treatment .    .  54 

Fractures  of  the  Superior  Maxilla 55 

Treatment 56 

Fractures  of  the  Inferior  Maxilla 58 

Treatment 61 

CHAPTER  III 

Fractures  of  the  Vertebrae 72 

Treatment 81 

CHAPTER  IV 

Fractures  of  the  Ribs 91 

CHAPTER   V 

Fractures  of  the  Sternum 96 

CHAPTER   VI 

Fractures  of  the  Pelvis 99 

Treatment 101 

Rupture  of  the  Urethra 103 

Rupture  of  the  Urinary  Bladder 104 

13 


14  TABLE    OF    CONTENTS 

CHAPTER    VII  pAGE 

Fractures  of  the  Clavicle 106 

Treatment  in  Adults 109 

Treatment  in  Children    ....             113 

Operative  Treatment 116 

CHAPTER    VIII 

Fractures  of  the  Scapula     118 

Treatment 1 1 9 

CHAPTER   IX 

Fractures  of  the  Humerus 121 

Fractures  of  the  Upper  End  of  the  Humerus    . 1 21 

Diagnosis 126 

Treatment 137 

Fracture  of  the  Upper  End  of  the  Humerus  with  a  Dislocation  of  the  Upper 

Fragment 1 42 

Fractures  of  the  Shaft  of  the  Humerus 144 

Fractures  of  the  Shaft  with  Little  Displacement 146 

Fractures  of  the  Shaft  with  Considerable  Displacement 15 1 

Fractures  of  the  Shaft  in  the  New-born 153 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus 153 

Malignant  Disease  Associated  with  Fracture  of  Bone .  155 

Fractures  of  the  Elbow 155 

Diagnosis       164 

Treatment 1 76 


CHAPTER    X 

Fractures  of  the  Bones  of  the  Forearm 187 

Fractures  of  Both  Radius  and  Ulna 187 

Treatment 194 

Nonunion  of  Fractures 207 

Fractures  of  the  Olecranon 210 

Treatment 213 

Tetanus 219 

Colics''  Fracture 219 

Diagnosis      227 

Treatment 232 


CHAPTER   XI 

Fractures  of  the  Carpus,  Metacarpus,  and  Phalanges 242 

Fractures  of  the  Carpus 242 

Fractures,  of  the  Metacarpus 245 

Fractures  of  the  Phalanges -5' 

Open  Fractures  of  the  Phalanges 254 


TABLE    OF    CONTENTS  I  5 


PACE 


CHAPTER   XII 

Fractures  of  the  Femur 256 

Fracture  of  the  Hip  or  Neck  of  the  Femur 256 

Treatment 265 

Operative  Treatment 274 

Fracture  of  the  Neck  of  the  Femur  in  Childhood 274 

Fracture  of  the  Shaft  of  the  Femur 278 

Treatment 279 

Subtrochanteric  Fracture  of  the  Femur 295 

Supracondyloid  Fracture  of  the  Femur 296 

Ambulatory  Treatment  of  Fracture  of  the  Thigh 299 

Fracture  of  the  Thigh  in  Childhood 305 

Separation  of  the  Lower  Epiphysis  of  the  Femur 309 

Treatment         314 

Traumatic  Gangrene 317 

Septicemia 317 

Malignant  Edema 317 

Fat  Embolism  ..., 318 


CHAPTER    XIII 

Fractures  of  the  Patella 319 

Treatment 324 

Open  Fracture  of  the  Patella 333 

Operation  in  Recent  Closed  Fractures  of  the  Patella 337 


CHAPTER   XIV 

Fractures  of  the  Leg 341 

Treatment 35 1 

Fractures  with  Little  or  No  Displacement 351 

Fractures  with  Considerable  Immediate  Swelling 354 

Fractures  Difficult  to  Hold  Reduced 365 

Treatment  of  Open  Fractures  of  the  Leg 369 

1 hrombosis  and  Embolism 378 

Pott's  Fracture 379 

Treatment 382 

Open  Pott's  Fracture 394 

CHAPTER    XV 

Fractures  of  the  Bones  of  the  Foot 396 

Fracture  of  the  Astragalus 396 

Open  Fracture  of  the  Astragalus  and  Os  Calcis 401 

Fracture  of  the  Metatarsal  Bones 401 

Fracture  of  the  Fhalanges 402 

CHAPTER    XVI 

Anatomical  Facts  Regarding  the  Epiphyses 403 


1 6  TABLE  OF  CONTEXTS 

CHAPTER    XVII  page 

The  RSntgen  Ray  and  Its  Relation  to  Fractures 409 

By  Dr.  E.  A.  Codman 

CHAPTER    XVIII 
The  Employment  of  Plaster-of-Paris 425 

CHAPTER    XIX 
The  Ambulatory  Treatment  of  Fractures 440 

BIBLIOGRAPHY 449 

INDEX 453 


THE  TREATMENT  OF   FRACTURES 


CHAPTER  I 
FRACTURES  OF  THE  SKULL 

The  skull  is  the  brain's  protection.  In  cases  of  fracture  of  the 
skull  the  injury  to  the  brain  is  of  paramount  importance.  The 
immediate  damage  to  the  brain  may  be  caused  by  direct  pressure 
of  bony  fragments,  by  pressure  due  to  hemorrhage  from  torn 
vessels  within  the  skull,  by  bruising  of  the  brain  itself,  or  by 
cerebral  edema.  Great  interest  attaches  to  serious  head- 
injuries,  not  only  because  the  brain  may  be  damaged,  but  more 
especially  because  the  lesions  are  often  obscured  by  an  intact 
scalp.  A  proper  determination  of  the  conditions  existing  after  a 
given  head-accident  necessitates  careful  observation  of  symptoms, 
combined  with  good  judgment  in  interpreting  the  signs  present. 

Concussion  and  Contusion  of  the  Brain. — A  concussion  and 
a  contusion  of  the  brain  associated  with  minute  bruising  of  brain- 
tissue  will  exist  after  all  injuries  of  importance  to  the  skull. 

The  symptoms  of  concussion  are  varied  according  to  the 
severity  of  the  injury.  Following  slight  concussion,  the  individ- 
ual is  stunned  by  the  accident ;  there  is  simple  vertigo,  possibly 
mental  confusion  lasting  but  a  short  time.  After  severe  concus- 
sion there  will  follow  a  momentary  loss  of  consciousness,  or  there 
may  be  unconsciousness  of  longer  duration.  Vomiting  may 
occur.  Headache  will  probably  be  present.  Following  a  still 
more  severe  concussion,  the  patient  will  be  profoundly  uncon- 
scious for  a  long  period.  The  sphincters  will  be  relaxed  ;  hence 
involuntary  micturition  and  defecation.  The  pulse  will  become 
feeble  and  slow  along  with  the  general  systemic  depression.    The 

2  17 


1 8  FRACTURES    OF    THE    SKULL 

pupils  still  react  to  light.  The  temperature  will  be  subnormal. 
It  is  impossible  clinically  to  distinguish  between  concussion  and 
contusion  of  the  brain.  The  pathological  differences  are  more 
or  less  artificial. 

Laceration  of  the  Brain. — If  there  is  laceration  of  the  brain, 
the  symptoms  of  concussion  will  be  present  to  a  marked  degree, 
and  will  be  characterized  by  immediate,  pronounced,  and  long- 
continued  unconsciousness.  After  recovery  from  the  initial 
shock  of  the  accident  fever  will  be  present,  which  may  rise  to 
1030  or  1040  F.  Concussion  is  never  associated  with  feverish- 
ness.  Early  fever  is  a  sign  of  laceration.  Mental  irritability 
and  restlessness  will  mark  returning  consciousness.  If  the  motor 
areas  of  the  brain  are  involved,  then  signs  of  irritation  will  ap- 
pear— namely,  muscular  twitchings  and  spasms  according  to  the 
motor  centers  implicated. 

Compression  of  the  Brain. — Slight  hemorrhages  do  not  cause 
symptoms  of  compression  ;  neither  do  slight  depressions  of  the 
cranial  bones.  Before  symptoms  of  compression  appear,  the 
cranial  cavity  must  be  impinged  upon  to  a  very  considerable  ex- 
tent. If  the  compression  is  sudden  and  limited,  there  is  an  irri- 
tation of  the  parts  involved,  which  is  manifested  by  restlessness 
and  delirium  and  by  twitching  of  certain  groups  of  muscles  ;  the 
pulse  is  hard  and  slow.  If  the  compression  is  gradual,  whether 
it  be  localized  or  diffused,  the  brain  accommodates  itself  for  some 
time  to  the  new  conditions  ;  the  appearance  of  the  symptoms  of 
local  pressure  is  delayed,  although  they  may  be  relatively  sudden 
in  their  onset.  Following  the  muscular  spasms  and  twitchings 
due  to  the  sudden  onset  of  pressure  there  may  appear  symptoms 
of  paresis  and  paralysis.  Loss  of  power  in  the  face  or  arm  or  leg 
indicates  the  seat  of  the  lesion  to  be  about  the  fissure  of  Rolando, 
upon  the  side  of  the  brain  opposite  to  the  affected  side.  Dilatation 
of  the  pupil  of  one  side  will  be  noticed  if  there  is  pressure  upon 
the  third  nerve  at  the  base  of  the  skull.  This  pupil  will  not  react 
to  light.  As  the  pressure  of  the  hemorrhage  increases,  the  symp- 
toms will  again  become  more  general  ;  convulsive  movements  of 
the  limbs  and  body  appear,  and  the  drowsiness  or  stupor  increases 
to  profound  unconsciousness  ;  the  pulse  becomes  rapid  and 
small  ;  and   the   respiration   frequent,  shallow,  and   sighing,  or  it 


INTRADURAL  HEMORRHAGE 


19 


passes  into  stertor  and  Cheyne-Stokes'  breathing  as  the  condition 
becomes  immediately  grave  ;  the  temperature  rises  high.  Focal 
symptoms  may  exist  from  pressure  by  bone  or  blood-clot,  apart 
from  loss  of  consciousness. 

Extradural  Hemorrhage  (see  Figs.  1,2). — The  most  impor- 
tant symptom  of  intracranial  hemorrhage  is  the  interval  of  con- 
sciousness that  exists  from  the  time  of  the  injury  to  the  onset  of 
unconsciousness.  Unconsciousness  incases  of  intracranial  hem- 
orrhage is  clue  to  an  increase  of  the  intracranial  pressure  caused 
by  the  presence  of  free  blood.     An  interval  of  consciousness 


Fig.  1. — Fracture  of  skull  with  middle 
meningeal  hemorrhage.  Compression  of 
brain  by  blood. 


Fig.  2.  —  Fracture  of  skull  with  de- 
pressed fragments.  Compression  of  brain 
by  bone. 


exists  in  these  instances  in  from  one-half  to  two-thirds  of  all 
cases.  In  the  cases  of  hemorrhage  which  occur  without  an  in- 
terval of  consciousness  (unconsciousness  coming  on  immediately 
upon  the  receipt  of  the  injury)  it  must  be  that  the  injury  is  so 
severe  that  the  unconsciousness  caused  by  the  concussion  and 
laceration  of  the  brain  is  continuous  with  the  unconsciousness 
from  hemorrhage.  The  unconsciousness  of  concussion  is  con- 
tinued over  into  the  coma  of  compression.  The  duration  of  the 
interval  of  consciousness  may  vary  within  very  wide  limits  :  it 
may  be  a  few  moments,  it  may  be  three  months. 


20 


FRACTURES    OF    THE    SKULL 


The  sources  of  intracranial  hemorrhage,  whether  from  the 
middle  meningeal  artery  (see  Fig.  3)  or  its  branches  (see  Fig.  4), 
from  the  middle  cerebral  arteries,  from  the  veins  of  the  pia  mater, 
from  the  inner  surface  of  the  dura,  from  the  sinuses  of  the  brain, 
or  from  lacerated  brain-tissue,  can  not  be  easily  differentiated 
short  of  operatiye  procedure.  There  is  one  condition  which  is 
not  to  be  overlooked  in  connection  with  the  question  of  hemor- 
rhage— namely,  the  period  of  semiconsciousness  which  some- 
times follows  concussion  and  laceration,  and  gives  rise  to  the 
suspicion  of  some  more  serious  gross  lesion.  To  illustrate  :  A 
young    girl    received  a  severe    blow   upon  the    head.      A    true 


Fig.  3.  —  Frontal  section  of  skull. 
Middle  meningeal  hemorrhage.  The 
dura  bulges  inward  toward  skull  cavity 
(diagram). 


~4nUr.  brctnehe. 


^Q 


Rupture 
of  artery 


Fig.  4. — A  case  of  rupture  of  middle  men- 
ingeal artery.  Preparation  of  dura  viewed 
from  outer  side  (Warren  Museum). 


Euplure  on  larger  scale , 
black  bristle  in  lumen 
,  of  artero  ■ 


Middle  meninjr 
gf,  fiost   branch. 


period  of  unconsciousness  followed.  There  were  no  external 
evidences  of  hemorrhage.  Convulsive  movements,  deviation  of 
the  eyes,  and  disturbance  of  the  pupils  were  absent.  The 
breathing  was  regular  and  of  normal  character.  Notwithstand- 
ing the  absence  of  other  untoward  symptoms,  complete  con- 
sciousness did  not  return  for  a  number  of  days  or  even  of  weeks. 
In  such  a  case,  after  a  number  of  days  the  question  naturally 
presents  itself,  Have  we  not  to  do  with  a  hemorrhage,  and 
should  not  trephining  be  considered?  The  absence  of  all  symp- 
toms excepting  the  unconsciousness  should  lead  to  the  suspicion 
that  we  have  to  do  with  a  mental   state  rather  than  with  a  gross 


THE  FRACTURE  OF  THE  SKULL 


21 


lesion.  Hysteroicl  semiconsciousness  (Walton)  supervening  upon 
a  blow  is  not  to  be  mistaken  for  the  deepening  unconsciousness 
which  indicates  hemorrhage. 

Subarachnoid  Serous  Exudation  (Cerebral  Edema). — A 
severe  blow  upon  the  head,  with  or  without  fracture  of  the  skull, 
may  result  in  a  local  bruising  and  in  congestion  and  swelling  of 
the  brain-tissue,  with  serous  exudation  into  the  subarachnoid 
space,  either  with  or  without  edema  of  the  brain-substance.  If 
this  accumulation  of  fluid  occurs  over  the  motor  area,  localized 
symptoms,  as  if  of  hemorrhage,  may  appear.  The  lesion  is  usu- 
ally self-limited,  the  resulting  paralysis  disappearing  in  the  course 
of  a  few  days.  The  careful  observation  of  the  onset  and  sequence 
of  the  signs  of  compression  is  of  the  very  greatest  importance, 


Fig.  5. — Splintering;  of  inner  table;  cross-sections;  diagrammatic:  a,  Usual  form  of 
punctate  fracture ;  b  shows  that  a  linear  fracture  may  be  much  more  extensive  internally 
than  externally. 

for  it  is  by  a  proper  interpretation  of  these  localizing  symptoms 
that  the  surgeon  is  led  to  operate,  and  then  is  enabled  to  remove 
the  compressing  blood-clot  or  the  depressed  fragment  of  bone. 


THE  FRACTURE  OF  THE  SKULL 
Whether  the  wound  of  the  bone  is  compound  or  simple,  open 
or  closed,  is  of  comparatively  little  importance,  because  of  the 
very  general  recognition  and  employment  of  aseptic  and  antisep- 
tic methods.  A  knowledge  of  the  nature  of  the  fracture  will 
help  in  determining  the  injury  to  the  brain.  If  there  is  a  per- 
forating fracture,  or  if  the  fragments  are  comminuted  or  depressed, 
then  it  is  highly  probable  that  a  tremendous  or  sharply  localized 
force  has  been  exerted  upon  the  bone,  and  that,  in  consequence, 
the  injury  to  the  underlying  brain  is  serious.      It  is  a  generally 


22 


FRACTURE    OF    THE    SKULL 


accepted  fact  that  the  skull  may  be  simply  contused  and  the  great 
lateral  sinus  ruptured,  with  resulting  fatal  hemorrhage.  It  is 
likewise  true  that  the  bone  may  present  but  a  fissure,  but  if  that 
fissure  crosses  the  middle  meningeal  artery,  or  any  of  its  branches, 
they  may  be  torn  across,  and  the  consequent  hemorrhage  and 
associated  intracranial  pressure  will  prove  disastrous  unless 
checked  by  surgical  interference.  On  the  other  hand,  the  bone 
in  the  frontal  region  may  be  greatly  damaged,  literally  crushed, 


Fig.  6. — Case  of  compound  depressed  fracture  of  the  frontal  bone.     Note  extent  of  depression. 
Recovery  (Harrington). 


and  yet  no  grave  symptoms  arise  (see  Fig.  6).      The  extent  of 
the  bone-lesion  is,  however,  of  the  greatest  importance. 

Fractures  of  the  Vault  of  the  Skull  (see  Fig.  8). — Frac- 
tures of  the  vault  of  the  skull  without  involvement  of  the  bast- 
arc  much  more  unusual  than  is  generally  supposed.  More  than 
two-thirds  of  all  fractures  of  the  vault  are  associated  with  frac- 
ture of  the  base  of  the  skull  (see  Figs.  8,  9,  10,  1  1).  Evidences 
of  fracture  of  the  vault  are  determined  by  sight  and  touch.  A 
wound  in  the  scalp  may  disclose  the  fractured  bone.      Whether 


Fig.  8. — Depressed  fracture  of  fron- 
tal bone  from  front,  showing  depres- 
sion of  fragments  (Warren  Museum, 
specimen  7951). 


Fig.  9. — Same  as  figure  8  ;  inner  surface  from 
below  ;  shows  excess  of  bone-formation. 


Fig.  10. — Depressed  fracture  of  right 
frontal  bone:  a,  Point  toward  vertex:  b, 
anterior  corner;  c,  lower  outer  end  (War- 
ren Museum,  4721). 


Fig.  11. — Same  from  within  ;  letters  as 
in  figure  10.  Fracture  shows  depression 
without  much  new bone-formalion( Warren 

Museum,  4721). 


24 


FRACTURES    OF    THE    SKULL 


this  is  a  mere  fissure  or  a  single  or  a  comminuted  fracture, 
whether  depressed  or  not  below  the  general  surface  of  the 
normal  skull,  can  be  determined  only  by  careful  inspection. 
A  fissure  of  the  bone  may  be  difficult  of  recognition.  It  must 
be  remembered  in  this  connection  that  blood  can  not  be  wiped 
from  a  fissure,  whereas  from  the  normal  suture  lines  it  can  readily 
be  wiped  away.  Blood  may  be  seen  escaping  through  a  fissure. 
Torn  periosteum  must  not  be  confused  with  a  fissure  of  the  bone. 
A  hematoma  of  the  scalp  may  suggest  a  depressed  fracture  of 
the  skull  (see  Fig.  12).     The  center  of  the  blood-tumor  is  soft ; 


Fig.  12. — No  fracture  of  skull.     Hematoma  of  scalp,  the  depressed  center  and  firm  edge  of 
which  often  simulate  fracture. 


the  edges  are  edematous  and  hard.  If  the  finger  be  pressed 
firmly  into  the  soft  center,  an  intact  skull  generally  will  be  felt. 
The  uniform  edge  of  a  hematoma  is  unlike  the  irregular  bom- 
edge  of  a  fracture. 

Fracture  of  the  Base  of  the  Skull  (see  Figs.  13,  14,  15). — 
It  is  not  uncommon  to  discover  that  what  in  the  vault  appears  to 
be  a  simple  fissure  continues  down  to  and  involves  the  base  of 
the  skull.  Fractures  of  the  base  of  the  skull  are  usually  re- 
garded, and  rightly  so,  as  more  serious  than  fractures  of  the 
vault.  A  greater  trauma  being  necessary  to  cause  the  fracture, 
the  cerebral   disturbance   is   more   pronounced   and   vital    parts 


FRACTURE    OF    THE    BASE    OF    THE    SKULL 
Crista  galli. 


25 


Anterior  fossa. 


Foramen  rotundum. 
Anterior  branch  middle 
meningeal  artery. 

Foramen  ovale. 
Foramen  spinosum. 

Petrous  portion  tem- 
poral bone. 

Lateral  sinus. 


Cribriform  plate,  foramina 
for  olfactory  nerves. 


Optic  foramen. 


_  Middle  fossa. 


Foramen  lacerum  medium. 
Depression  for  Gasserian 

ganglion. 
Meatus  auditorius 

internus. 
Foramen  lacerum 

posterius. 


Foramen  magnum. 


Posterior  fossa. 


Fig.  13. — Base  of  skull,  from  inside  and  above. 


Fig.  14.  —  Punctate  fracture  entering 
posterior  fossa.  From  the  punctate  de- 
pression a  line  of  fracture  extends  down- 
ward and  backward  (Warren  Museum, 
specimen  965). 


Fig.  15. — Inner  view  of  figure  14,  showiin 
comminution  of  inner  table  of  skull. 


26 


FRACTURES    OF    THE    SKULL 


are    endangered.      These    fractures    of    the    base     often     open 
into  cavities  which   it  is  impossible  to   keep  surgically  clean — 

namely,  the  cavities  of  the  naso- 
pharynx and  the  ear.  The 
danger  of  septic  infection,  there- 
fore, in  such  fractures  is  very 
great.  About  eighty-five  per 
cent,  of  basic  fractures  originate 
in  the  vault — i.  c,  are  caused  by 
an  extension  of  a  linear  fracture 
of  the  vault  to  the  base.  A  few 
basic  fractures  are  due  to  forces 
acting  from  below  and  thus  caus- 
ing a  penetration  of  the  base  of  the  skull  by  other  bones.  The 
facial  bones  may  be  forced  up  into  the  anterior  fossa  (see  Fig.  16). 


Fig.  16. — Fracture  of  base  of  skull  ; 
impaction  of  nasal  and  part  of  ethmoid 
bones,  which  project  into  the  interior  of 
the  cranium.  Male,  aged  twenty-eight; 
diagnosis,  fracture  of  nose.  Died  of  men- 
ingitis (after  Helferich). 


Posterior  nares. 


Glenoid  fossa. 


External  pterygoid 
plate. 


Fig.  17.— Showing  thinness  of  the  roof  of  the  glenoid  fossa,  which  is  occasionally  broken  by 
the  condylar  process  of  the  inferior  maxilla  when  a  blow  is  received  on  the  jaw. 


The  articular  process  of  the  inferior  maxillary  bone  may  be  pushed 
up  through  the  glenoid  fossa  of  the  temporal  bone  (see  Fig.  17) 


SYMPTOMS  OF  FRACTURE  OF  THE  BASE 


27 


into  the  middle  fossa  by  a  blow  upon  the  chin,  particularly  if  the 
jaw  is  relaxed.  The  vertebral  column  may  be  forced  up  into  the 
posterior  fossa  through  a  fracture  of  the  occiput. 

Symptoms  of  Fracture  of  the  Base. — Hemorrhage  from  the 
ear,  from  the  nose,  or  from  the  mouth  may  be  present ;  also 
subconjunctival  hemorrhage.  Hemorrhage  beneath  the  pharyn- 
geal mucous  membrane  may  occur.  Escape  of  cerebrospinal 
fluid  from  the  ear  and  nose  occurs,  and  escape  of  brain-tissue 
from  the  skull.  Injuries  to  various  nerves  occur.  Associated 
with  these  local  signs  may  be  the  general  signs  of  concussion  or 
laceration  of  the  brain. 

If  the  orbital  plate  of  the  frontal  bone  is  broken,  blood  will 

Frontal  sinus. 


Sphenoidal  sinus.        Cribriform  plate. 

Fig.  18. — Median  section.     Anterior  portion  of  skull,  showing  thinness  of  the  ethmoid  plate, 
which  alone  separates  the  cavities  of  nose  and  skull. 


gravitate  into  the  orbit ;  ecchymosis  of  the  lids  and  subconjunc- 
tival hemorrhage  will  appear.  There  may  be  greater  tension 
of  that  eyeball  upon  the  affected  side,  detected  by  palpating  the 
globe  through  the  closed  lid.  Subconjunctival  hemorrhage 
may  appear  from  a  fracture  of  the  malar  or  superior  maxillary 
bones. 

If  the  cribriform  plate  of  the  ethmoid  is  fractured,  hemorrhage 
from  the  nose  will  occur  (see  Fig.  18).  Impairment  of  the  sense 
of  smell  may  exist  if  the  olfactory  nerves  become  involved  in  the 
fracture.  Blood  may  trickle  from  a  fracture  of  the  base  into  the 
pharynx,  be  swallowed,  and  later  vomited.  Epistaxis,  of  course, 
may  be  due  to  a  blow  upon  the  face  without  fracture  of  the  base. 


28 


FRACTURES    OF    THE    SKULL 


If  inspection  discloses  a  broken  nose  or  ecchymosis  of  the  face  or 
the  skin  of  the  forehead,  it  is  very  probable  that  the  minor  acci- 
dent has  occurred.  Most  fractures  of  the  base  involve  the  middle 
fossa. 

If  the  petrous  portion  of  the  temporal  bone  is  fractured,  several 
important  signs  appear  (see  Fig.  19).  If  the  tympanum  is  torn, 
hemorrhage  from  the  external  auditory  meatus  is  sure  to  follow. 
If  this  hemorrhage  is  continuous,  it  is  significant ;  if  it  is  trifling 
and  temporary,  it  is  probably  unimportant.  Cerebral  tissue 
may  escape  from  the  nose,  thus  establishing  the  seat  of  the 
lesion.  Cerebrospinal  fluid  may  likewise  escape  from  the 
ear.       Cerebral    tissue  may  also   appear  at  the   external    audi- 


Fig.  19. — Fracture  of  the  base  of  the  skull,  involving  the  middle  and  posterior  fossse  on  the 
left  (Warren  Museum,  5106). 


tory  meatus.  Any  of  these  signs  is  conclusive  evidence 
that  the  base  of  the  skull  is  fractured  and  that  there  is  a 
lesion  of  the  brain.  Lesions  of  the  facial  (seventh)  and 
auditory  (eighth)  nerves  lying  within  the  bones  occur.  Lesions 
are  likewise  reported  of  the  fifth  nerve,  because  of  its  lying 
upon  the  petrous  portion  of  the  temporal  bone.  Subconjunc- 
tival hemorrhage  may  appear,  owing  to  the  blood  working  its 
way  forward  and  through  the  sphenoidal  fissure  and  the  optic 
foramen.  A  primary  profuse  watery  discharge  from  the  nose 
or  the  ear  is  probably  cerebrospinal  fluid.  A  watery  discharge 
appearing  late  after  such  an  injury  is  likely  to  be  serum  from 
a  blood-clot.  The  optic  nerve  may  be  involved,  and  complete 
loss  of  vision  result. 


CERTAIN    CAUSES    OF    UNCONSCIOUSNESS 


29 


Fig.  20. — The  three  fossa;  of  the  base 
of  the  skull. 


If  the  posterior  fossa  (see   Fig.   20)  is  involved  in   the  frac- 
ture, there  may  be  hemorrhage  into  the  pharynx.      Ecchymosis 
under  the  pharyngeal  mucous  membrane  may  be  present  without 
actual  rupture  of  the  mucous  mem- 
brane.     A  fullness  may  be  detected 
by  palpation   in  the  posterior  wall 
of  the  pharynx,  if  the  hemorrhage 
there  is  considerable.      Ecchymosis 
j  ust  in  front  of  the  mastoid  process, 
or  a  hematoma  and  puffy  swelling 
over  the  seat  of  the  fracture,  may 
determine  its  location. 

Certain  Causes  of  Unconscious- 
ness.— There  are  certain  conditions 
associated  with  loss  of  conscious- 
ness and  delirium  which  must  be 
differentiated  from  intracranial  le- 
sions. These  conditions  are  (a)  the 
coma  from  opium-poisoning ;  (b) 
the     unconsciousness    in     uremia  ; 

(c)  the  loss  of  consciousness  from  apoplexy  ;  (d)  alcoholic  coma  ; 
and  (r)  hemorrhagic  internal  pachymeningitis. 

Coma  from  Opium-poisoning  :  The  patient  can  be  aroused 
unless  the  poisoning  is  extremely  profound,  and  can  be  made  to 
understand,  and  will  even  reply  to  an  inquiry.  The  face  at  first 
is  pale,  later  it  is  flushed  and  swollen.  The  skin  is  warm  and 
moist.  The  respiration  is  slow.  The  temperature  is  subnormal. 
The  pulse  is  slow  and  full.  The  pupils  are  strongly,  immovably, 
and  symmetrically  contracted.     The  reflexes  may  be  absent. 

The  Unconsciousness  in  Uremia :  The  patient  can  not  be 
aroused.  The  face  is  white,  edematous,  and  puffy.  The  breath 
has  a  sweetish  odor.  The  respiration  is  frequent  and  irregular. 
The  temperature  is  normal.  The  pulse  is  rapid.  The  pupils 
are  dilated  and  sluggish.      The  urine  contains  albumin. 

The  Unconsciousness  from  Apoplexy  :  The  patient  can  not  be 
aroused.  The  respiration  is  slow,  irregular,  and  stertorous. 
The  temperature  is  subnormal  at  first ;  if  a  fatal  termination  is 
probable,  the  temperature  is  high.     The  pupils  are  dilated.      Uni- 


30  FRACTURES    OF    THE    SKULL 

lateral  paralysis  of  the  face  and  the  extremities  usually  is  present. 
The  affected  extremities  are  warmer  than  those  of  the  other  side. 
The  limbs  may  be  relaxed,  but  in  watching  the  patient  carefully 
evidences  of  hemiplegia  will  appear. 

Alcoholic  Coma  :  The  patient  can  be  aroused  by  pressure  upon 
the  supra-orbital  nerves — sometimes,  however,  with  great  diffi- 
culty. The  breath  may  be  alcoholic.  The  face  is  flushed.  The 
respiration  is  regular.  The  pulse  is  rapid.  The  temperature  is 
normal  or  low.  The  pupils  are  normal.  There  is  an  absence  of 
the  positive  signs  of  a  cerebral  lesion.  The  temperature  in  cere- 
bral laceration  is  elevated.  Alcoholic  delirium  will  present  an 
elevated  temperature,  but  along  with  the  elevated  temperature 
of  a  lacerated  brain  there  will  be  symptoms  characteristic  of  a 
damaged  brain. 

Hemorrhagic  Internal  Pachymeningitis :  The  occurrence  of 
apoplectic  seizures  during  the  course  of  this  disease  makes  it  im- 
portant that  it  be  recognized  in  connection  with  the  distinctly 
traumatic  hemorrhages  under  consideration.  The  characteristic 
course  shows  an  acute  diffused  affection  of  the  brain,  usually  in 
an  elderly  man  and  with  severe  symptoms.  An  acute  attack 
is  followed  by  a  fair  recovery  and  by  intervals  of  comparative 
health.  During  these  intervals  of  comparative  health  the  patient 
has  some  headache,  slight  diminution  of  intelligence,  impairment 
of  memory,  drowsiness,  partial  paralysis  of  the  limbs  (usually 
unilateral),  disturbances  of  speech,  and  sudden  mental  excitement 
without  cause  mixed  with  symptoms  of  paralytic  dementia.  Evi- 
dences of  a  sudden  and  increasing  compression  are  headache, 
drowsiness,  loss  of  consciousness,  some  fever,  a  pulse  of  com- 
pression, and  sometimes  initial  symptoms  of  irritation.  The  diag- 
nosis is  assisted  by  the  etiology  and  history  of  the  case.  In 
middle  meningeal  hemorrhage  a  blow  is  necessary  to  cause 
alarming  symptoms,  whereas  in  hemorrhagic  pachymeningitis 
a  very  trivial  injury  or  none  at  all  is  common.  The  longer 
duration  of  the  symptoms  would  help  to  decide  against  middle 
meningeal  hemorrhage.  There  is  often  a  rigidity  of  the  limbs  in 
hemorrhagic  pachymeningitis  which  is  absent  in  middle  menin- 
geal hemorrhage  cases. 

When   called  upon  to  sec  a  case  of  head-injury,  it  must  be 


EXAMINATION    OF    THE    PATIENT  3  I 

remembered  that  the  lesion  can  not  always  be  determined  by  the 
first  observation  of  the  patient.  It  is  absolutely  necessary  that 
there  be,  upon  the  part  of  the  physician,  a  clear  understanding 
of  the  method  of  onset  and  the  sequence  of  symptoms  from  the 
receipt  of  the  injury.  Isolated  signs  are  of  less  importance  than 
relative  symptoms. 

Examination  of  the  Patient. — The  following  comprehensive 
method  of  examining  an  individual  who  has  received  a  severe 
injury  to  the  head  should  be  carefully  followed,  bearing  in  mind 
always  the  possible  cranial  and  intracranial  lesions,  and  remem- 
bering that  a  fracture  of  the  skull  as  such  is  of  secondary  impor- 
tance, that  an  injury  to  the  intracranial  vessel  is  serious,  and  that 
a  lesion  of  the  brain  itself  is  most  important. 

If  with  brain  symptoms  there  is  no  visible  injury  to  the  skull, 
the  head  should  be  shaved  to  facilitate  careful  examination. 
Acute  localized  pain  suggests  the  seat  of  fracture  when  it  is  not 
visible. 

When  was  the  accident  ?  How  much  time  has  elapsed  be- 
tween the  accident  and  the  first  accurate  observation  ? 

What  was  the  accident  ?     Was  it  a  fall  or  a  blow  ? 

What  is  the  age  of  the  patient  ?  Are  the  arteries  atheroma- 
tous, and  therefore  easily  ruptured  by  trivial  injury?  Is  it  the 
skull  of  a  child — which  is  softer  and  less  brittle  than  that  of  an 
adult? 

What  was  the  condition  of  health  previous  to  the  accident? 
Was  it  poor — suggestive  of  kidney-disease  and  uremia  ?  Was 
the  man  alcoholic,  or  is  the  present  condition  masked  by  alcohol 
taken  subsequent  to  the  accident  ? 

The  General  Condition  of  the  Patient:  If  unconsciousness  is 
present,  was  its  onset  immediate,  or  was  there  a  lucid  interval 
after  the  accident  ?  Has  the  unconsciousness  been  continuous, 
and  is  it  deepening  or  lessening  ? 

What  are  the  evidences  of  shock  present  ?  What  is  the  con- 
dition of  the  pulse,  of  the  respiration,  of  the  skin  ?  What  is  the 
temperature  taken  in  the  rectum  ?  Has  vomiting  occurred  ? 
Have  there  been  involuntary  dejections  ?  Has  there  been  invol- 
untary micturition  ? 

The  Local  Condition  :  The  wound  of  the  scalp  or  skull  or 


32  FRACTURES    OF    THE    SKULL 

brain  may  be  evident.  If  hemorrhage  is  present,  what  is  its 
source  ?  Is  it  from  the  nose,  the  mouth,  the  ear,  or  into  the 
orbit  ?  When  did  the  hemorrhage  occur  ?  What  was  its  amount  ? 
Was  it  continuous  or  not  ?  Palpation  should  be  made  of  the 
skull,  the  neck,  the  face,  the  spine,  the  jaw,  and  the  temporo- 
maxillary  joint. 

Are  any  localizing  signs  present  ?  What  is  the  condition  of 
the  pupils,  and  of  the  muscles  of  the  face,  the  arms,  and  the 
legs?  What  is  the  condition  of  the  reflexes  and  of  the  respira- 
tion ?      Does  hemiplegia,  either  partial  or  complete,  exist  ? 

Finally,  the  whole  body  should  be  examined  systematically 
for  any  other  injuries  than  those  to  the  head  and  to  the  nervous 
system.  Associated  injuries,  if  discovered,  may  assist  in  inter- 
preting the  nature  of  the  cerebral  injury. 

A  diagnosis  must  be  based  upon  all  available  evidence.  One 
will  have  to  consider  concussion  and  laceration  of  the  brain  and 
pressure  upon  the  brain  by  serum,  blood,  and  bone.  The 
important  signs  to  be  studied  in  diagnosis  are  the  different  aspects 
of  unconsciousness  ;  the  relative  and  actual  conditions  of  the 
respiration,  pulse,  and  temperature  ;  the  occurrence  of  hemor- 
rhage ;  irritability  in  temperament  and  in  muscle  ;  localizing 
signs  of  pressure.  If  the  symptoms  are  not  positive,  if  there  is 
no  history  of  trauma,  if  the  history  of  a  lucid  interval  preceding 
unconsciousness  is  doubtful,  or  if  there  is  no  history  at  all,  then 
the  diagnosis  will  be  most  difficult.  It  is  when  positive  symp- 
toms are  absent  that  one  must  particularly  consider  those  condi- 
tions already  mentioned  in  which  coma  is  a  prominent  sign — 
namely,  opium-poisoning,  uremia,  apoplexy,  alcoholism,  and 
pachymeningitis  haemorrhagica. 

General  Observations. — An  unconscious  man  having  a  scalp 
wound  and  a  breath  smelling  of  liquor  is  not,  necessarily, 
drunk.  He  may  have  an  intracranial  lesion.  Multiple  lesions 
may  be  present  in  any  case.  A  diffuse  lesion  may  obscure  a 
localized  lesion.  Not  only  must  the  location  of  a  lesion  be 
determined,  but  also  its  character,  if  possible.  The  symptoms 
must  be  recorded  in  the  order  of  their  appearance.  The  man- 
ner in  which  various  symptoms  develop  should  be  noted.  The 
danger    to    the    brain    is    greatest    in    perforating    and    sharply 


GENERAL    OBSERVATIONS  33 

depressed  fractures.  Slight  fissures  may  be  associated  with  grave 
hemorrhages.  Great  comminution  of  bone  may  be  devoid  of 
much  danger.  In  cases  of  compound  fracture  fissures  appar- 
ently closed  afford  the  possibility  of  cerebral  and  meningeal 
infection  through  dirt  having  entered  when  the  fissure  was  open. 

Unconsciousness  and  a  superficial  head-lesion,  with  or  without 
fracture  of  the  skull,  must  make  one  suspicious  of  an  intra- 
cranial lesion.  An  immediate  loss  of  consciousness  indicates  a 
diffused  contusion  or  concussion  of  the  brain.  If  the  primary 
unconsciousness  is  prolonged,  probably  hemorrhage  has  oc- 
curred, or  possibly  a  serous  exudation  with  its  resulting  pressure 
upon  the  brain.  If  there  is  a  conscious  interval  preceding  the 
unconsciousness,  a  hemorrhage  is  probable.  Momentary  uncon- 
sciousness means  concussion.  Recurring  unconscious  periods 
indicate  hemorrhage.  Deepening  unconsciousness  indicates  in- 
creasing intracranial  pressure — probably  hemorrhage.  Imme- 
diate profound  unconsciousness  suggests  hemorrhage  from  the 
rupture  of  an  intracranial  sinus. 

The  temperature  in  all  intracranial  lesions  is  usually  slightly 
above  normal.  Intoxication  and  shock  depress  the  temperature. 
In  a  small  intracranial  hemorrhage  there  will  be  a  slight  rise  of 
temperature,  perhaps  to  990  F.,  following  the  initial  drop  a  few 
hours  after  the  injury.  In  cerebral  laceration  one  finds  a  higher 
initial  temperature  than  in  hemorrhage,  and  in  fatal  cases  the 
temperature  remains  elevated.  If  the  temperature  rises  quickly 
and  early,  an  important  laceration  is  present ;  if  after  several 
hours  of  unconsciousness  the  temperature  remains  about  99  °  or 
99. 5°  F.,  there  is  probably  a  hemorrhage  rather  than  a  severe 
direct  lesion  ;  if,  on  the  other  hand,  the  temperature  rises  higher, 
there  is  a  cerebral  lesion,  alone  or  associated  with  a  hemorrhage. 
If  the  temperature  does  not  rise  very  high  and  advances  rather 
slowly,  there  is  a  contusion  or  a  concussion  with  slight  lacera- 
tion or  a  slight  hemorrhage.  A  slow,  full  pulse  with  stertorous 
respiration  suggests  pressure,  most  often  from  extradural  hemor- 
rhage. Early  and  very  slow  respiration  is  associated  with  pres- 
sure upon  the  medulla. 

Paralysis  of  the  limbs  and  the  face  is  characteristic  of  serous 
exudation,  hemorrhage,  or  bony  pressure.      Irregular  muscular 


34  FRACTURES    OF    THE    SKULL 

contractions  suggest  laceration  of  motor  areas.  Mental  disturb- 
ance may  be  due  to  cerebral  lesions.  That  brain-tissue  escapes 
from  the  ear  does  not  necessarily  signify  that  the  patient  will 
not  recover.  Fractures  of  the  base  of  the  skull  occur  without 
marked  symptoms  and  recover  without  the  necessity  of  operation. 
Treatment. — There  are  cases  of  injury  to  the  skull  so  serious 
that  it  is  evident  that  operation  will  be  of  no  avail.  There  are 
cases  of  simple  concussion  in  which  only  careful  nursing  is  de- 
manded. There  is  a  large  and  increasing  number  of  serious 
head-accidents  in  which  operative  interference  will  prove  of  great 
value.  The  collapse  from  shock  may  be  well-nigh  complete, 
but  restorative  measures  are  not  to  be  neglected  upon  this 
account.  If  hemorrhage  is  suspected,  stimulation  of  the  circu- 
lation must  be  very  guarded.  The  patient  should  be  placed  hori- 
zontally, with  the  head  slightly  raised,  and  kept  quiet.  The 
whole  body  should  be  wrapped  in  warm  blankets.  Warm 
water-bottles  should  be  put  on  the  outside  of  the  bed  about  the 
patient,  one  at  each  foot,  three  along  each  side  of  the  body. 
The  water  in  these  bottles  should  be  comfortably  warmed — 
ioo°  F.  Hot  water  is  never  to  be  used.  Patients  under  these 
circumstances  are  insensible  to  heat,  and  severe  burning  of  the 
skin  may  occur  if  very  hot  water  is  used  in  the  bottles. 

If  there  are  no  indications  for  immediate  operation,  and  local- 
izing symptoms  are  absent,  the  patient  is  to  be  treated  sympto- 
matically.  The  pulse  is  to  be  carefully  watched  to  detect  varia- 
tions in  strength,  rate,  and  rhythm.  The  character  and  frequency 
of  the  breathing  are  to  be  likewise  noted.  Gentle  stimulation  sub- 
cutaneously  by  sulphate  of  strychnin  (J|T  of  a  grain),  administered 
as  needed,  will  often  steady  a  pulse  remarkably.  A  special 
nurse  or  an  intelligent  watcher  should  be  with  the  patient  con- 
stantly, to  note  any  localizing  signs  of  pressure,  such  as  twitch- 
ing of  the  muscles  of  the  face  or  limbs  and  variations  in  the 
pupil,  to  record  movements  of  the  limbs,  and  to  make  hourly 
observations  of  the  pulse,  temperature,  and  respiration,  and  any 
variation  in  consciousness.  These  observations  will  be  of  in- 
estimable value  in  determining  diagnosis,  prognosis,  and  treatment. 

The  various  cavities  exposing  the  brain  to  infection  should  be 
cleansed. 


TREATMENT  OF  FRACTURES  OF  THE  SKULL         35 

The  Nose. — The  nose  should  be  douched  with  boric  acid  solu- 
tion (1  :  30),  and  plugs  of  sterilized  absorbent  cotton  should  be 
placed  in  each  nostril. 

The  Ear. — The  ear  should  be  douched  with  boric  acid  solu- 
tion (1  :  30),  and  dried  carefully  with  small  wisps  of  cotton. 
Boric  acid  powder  should  then  be  blown  gently  into  the  external 
auditory  meatus.  A  bit  of  sterilized  gauze  or  absorbent  cotton 
may  be  left  in  the  meatus. 

The  Scalp. — The  directions  for  cleansing  the  scalp  pertain  to 
cases  with  or  without  scalp  wounds  associated  with  important 
cerebral  symptoms.  The  whole  scalp  should  be  shaved, 
scrubbed  with  hot  water  and  soap,  with  chlorinated  soda 
solution  (1:20),  with  boiled  water,  and  then  with  corrosive 
sublimate  solution  (1  :  1000),  and  covered  with  a  dressing  of 
sterilized  gauze  that  has  been  moistened  in  a  solution  of  corro- 
sive sublimate  (1  :  5000).  The  wound  of  the  soft  parts  should 
be  carefully  irrigated  with  sterilized  salt  solution,  and  sponged 
and  swabbed  with  great  care  with  corrosive  sublimate  solution 
(1  :  5000).  The  swabs  used  should  be  tiny  ones,  so  as  to  reach 
to  the  smallest  recesses  of  the  wound.  Corrosive  sublimate 
solution  should  not  be  allowed  to  touch  the  brain-tissue. 

The  Mouth. — Thorough  cleansing,  writh  corrosive  sublimate 
solution  (1  :  3000),  of  the  teeth  and  tongue  and  all  the  folds  of 
the  mucous  membrane  about  the  lower  and  upper  jaws  is  impor- 
tant. The  swabbing  of  the  tonsils  and  the  posterior  pharyngeal 
wall,  the  care  of  the  nose  and  the  ear, — these  procedures  will 
reduce  to  a  minimum  the  chances  of  infection.  The  nose  and 
mouth  will  require  constant  attention.  The  ear  will  require  at 
least  daily  cleansing.  The  frequency  of  the  cleansing  required  will 
depend  very  largely  upon  the  amount  of  moisture  and  discharge 
from  the  part  involved.  If  the  packing  of  cotton  soon  becomes 
moistened,  the  douching  should  be  repeated,  and  fresh,  dry  pack- 
ing should  replace  the  old.  If  there  is  great  restlessness,  it 
may  be  necessary  to  restrain  the  patient,  that  he  may  not  harm 
himself.  This  is  done  by  means  of  a  sheet  folded  and  passed 
about  the  bed  and  body  of  the  patient. 

Operative  interference  is  demanded  in  penetrating  or  sharply 
depressed  fractures,  in  all  compound  fractures,  and  in  all  simple 


36 


FRACTURES    OF    THE    SKULL 


fractures  with  symptoms  of  intracranial  hemorrhage  increasing 
in  severity  or  distinctly  localized  (see  Figs.  21,  22,  23).  Opera- 
tion is  undertaken  in  these  cases  for  three  distinct  reasons  :  to 
insure  cleanliness,  to  elevate  and,  if  necessary,  remove  bony  frag- 
ments, and  to  check  hemorrhage. 
The  details  of  operative  treatment 
must  necessarily  be  omitted. 

All  cases  of  injury  to  the  head, 
even  cases  of  simple  nondepressed 
fracture  of  the  skull  without  symp- 
toms, are  to  be  watched  with  great 
care  by  trained  observers  for  at 
least  one  month  following  the  acci- 
dent, and  then  are  to  be  seen  at 
intervals  for  many  months  after- 
ward. The  reason  for  this  pro- 
longed observation  is  that  men- 
ingeal hemorrhage  may  develop 
in  the  immediate  future,  and  that  after  an  interval  of  months 
a  brain-abscess  may  manifest  its  presence. 


Fig.  21. — Sites  where  extradural  hemor- 
rhage is  usually  found. 


Fie.  22. — Location  of  anterior  branch  of  middle  meningeal  artery.  Draw  a  line  from 
idla  backward  [a  d ),  parallel  to  the  line  b  c.  from  the  lower  edge  of  the  orbit  through 
the  external  meatus.  Line  from  glabella  to  mastoid,  a  r.  From  the  middle  of  this  last  line, 
a  line  drawn  perpendicular  to  it  will  intersect  the  line  a  ti  at  about  the  site  of  the  artery.  A 
line  running  from  the  front  of  the  mastoid  perpendicular  to  the  line  b  c  intersects  a  d  at  about 
the  site  of  the  posterior  branch. 

In  fracture  of  the  base  with  pronounced  symptoms,  drainage 
of  the  fossa  involved,  whether  anterior,  middle,  or  posterior, 
should  be  considered.      It  has  occasionally  been  of  service. 


PISTOL-SHOT    WOUNDS    OF    THE    SKULL 


37 


Prognosis. — The  prognosis  of  head-injuries  is  the  prognosis 
of  their  complications  and  sequelae.  Prolonged  unconscious- 
ness is  not  usually  dangerous  in  itself.  Late  unconsciousness  is 
dangerous.  The  severity  rather  than  the  form  of  the  lesion  is 
to  be  made  the  basis  of  prognosis.  The  temperature  is  of  great 
value  in  prognosis.  By  its  persistent  depression  the  danger 
from  primary  shock  is  gauged  ;  a  little  later  in  the  course  of  the 
case  the  amount  of  hemorrhage  is  judged  by  it;  later  still,  its 
rapid  and  progressive  rise  will  denote  the  magnitude  or  severity 


Fig.  23. — Perpendicular  lines  fiom  the  mastoid  and  from  just  in  front  of  the  ear  include  the 
motor  area  of  the  central  convolutions.     The  fissure  of  Rolando  is  shown. 


of  a  meningeal  or  cerebral  lesion.  A  temperature  as  high  as 
1050  F.  is  of  grave  prognosis.  A  sudden  rise  of  temperature 
late  in'the  progress  of  a  case,  probably  due  to  a  meningitis,  or  a 
continued  subnormal  temperature  at  any  time  after  the  reaction 
from  the  primary  shock,  is  always  an  unfavorable  sign.  Symptoms 
often  change  suddenly  in  cases  apparently  doing  well.  One's 
prognosis  must,  therefore,  always  be  guarded. 


PISTOL-SHOT  WOUNDS  OF  THE  SKULL 
The  treatment  should  be  conducted  on  the  same  principles  as 
the  treatment  of  perforating  fractures  of  the  skull  by  a  sharp 
instrument.      The  wound   should   be  thoroughly  explored    and 


38  FRACTURES    OF    THE    SKULL 

thoroughly  cleansed  ;  this  often  calls  for  free  incisions  in  the 
scalp.  All  loose  fragments  should  be  removed,  including  the 
bullet,  if  readily  accessible.  Drainage  and  strict  asepsis  are 
essential  for  the  best  results.  Exploration  and  probing  for  the 
bullet  should  never  be  attempted  by  the  physician  in  charge  of 
the  case.  This  should  be  a  part  of  the  operative  procedure,  and 
should  be  undertaken  by  the  surgeon  only  under  strictly  anti- 
septic and  aseptic  precautions. 

LATER  RESULTS  OF  FRACTURE  OF  THE  SKULL 
Very  little  is  known  of  these  cases  in  this  country.  Dr. 
Bullard,  of  the  Boston  City  Hospital,  has  contributed  so  valu- 
able a  paper  upon  this  subject  that  the  results  are  here  stated  : 
Seventy  patients  were  examined  after  having  had  fracture  of  the 
skull  :  37  presented  no  symptoms  when  examined  some  time 
later.  The  most  frequent  consequences  were  headache,  deaf- 
ness, dizziness,  and  inability  to  resist  the  action  of  alcohol  on 
the  brain.  Out  of  15  cases  in  which  operation  (trephining) 
was  performed,  12  had  no  resulting  symptoms;  in  one  case  it 
was  doubtful  whether  the  symptoms  present  were  due  to  injury  ; 
in  one  case  the  symptoms  were  slight  (headache  rare,  tension  over 
the  wound  while  lying  in  bed).  The  other  case  was  deaf,  but  had 
no  other  trouble. 

Dr.  Bullard  concludes,  so  far  as  these  statistics  lead,  that 
those  cases  in  which  trephining  was  performed  have  shown  much 
better  results,  so  far  as  the  symptoms  previously  mentioned  are 
concerned,  than  those  in  which  no  operation  was  performed. 

CLINICAL  CASES  OF  HEAD  INJURY 
The  following  cases,  related  in  some  detail,  illustrate  a  few  of 
the  varieties  of  injuries  to  the  head  from  a  clinical  standpoint : 

Case  I. — A  fall  upon  the  head. — No  visible  evidences  of  injury. — An 
interval  of  consciousness  followed  by  unconsciousness. — Localizing  signs 
of  pressure. — Diagnosis,  middle  meningeal  hemorrhage  70/'///  fracture 
of  skull.  —  Operation. — Fracture  and  hemorrhage  found. — Recovery. 

M.   A.   B ,  sixty-nine  years  old,  a  spinster,   fell,  upon  being 

struck  by  a  coasting-sled,  one  and  one-half  hours  previous  to  the  exam- 
ination. 

Examination. — She  does  not  know  of  the  accident  which  has  be- 


ILLUSTRATIVE    CASES  39 

fallen  her.  She  talks  coherently.  She  recognizes  her  sister.  There 
is  slight  shock.  The  pulse  is  64  and  of  fair  strength;  the  respira- 
tion is  16;  the  temperature  is  97.  50  F.  There  is  bleeding  from  the 
right  ear.  There  is  some  dry  blood  about  the  nostrils.  There  is  no 
visible  external  injury.  There  is  no  paralysis.  All  the  superficial 
reflexes  are  present.  The  pupils  are  contracted  equally  and  react  to 
light.  The  patient  is  not  very  restless,  although  she  talks  consider- 
ably and  affirms  again  and  again  that  she  is  not  hurt. 

The  ears  were  washed  out  carefully  and  treated  antiseptically. 

She  vomited  two  or  three  times  during  the  night.  She  was  quite 
restless,  moving  and  turning  in  bed.  She  slept  two  or  three  hours 
altogether.  There  were  no  evidences  of  intracranial  pressure  in  the 
morning.  At  about  noon  of  the  second  day  she  talked  a  little  inco- 
herently.     She  did  not  answer  questions  as  readily  as  in  the  morning. 

At  3  o'clock  in  the  afternoon  of  the  second  day  examination  finds 
the  pupils  equal  and  reacting  to  light.  She  understands  what  is  said 
to  her,  but  does  not  talk  coherently  or  distinctly.  There  is  almost 
complete  paralysis  of  the  right  arm.  There  is  paresis  of  the  right  leg. 
The  face  is  not  paralyzed.  The  pulse  has  increased  in  rate  to  85  and 
is  particularly  full  and  bounding.  The  knee-jerk  is  much  less  active 
upon  the  right  than  upon  the  left  side. 

At  4.30  p.m.,  one  and  one-half  hours  after  the  previous  observa- 
tion, all  the  symptoms  were  considerably  intensified.  The  face  was 
uneven,  the  wrinkles  being  most  marked  on  the  left.  The  breathing 
was  becoming  labored  and  almost  stertorous.  It  was  hard  to  arouse 
the  woman.  She  moved  the  left  arm  freely.  The  right  arm  she  moved 
slightly  or  not  at  all.  There  were  no  abdominal  reflexes  active.  Bleed- 
ing from  the  right  ear  continued  to  a  slight  extent  all  day. 

A  diagnosis  of  middle  meningeal  hemorrhage  on  the  left  side  was 
made.      Immediate  operation  was  decided  upon. 

Under  ether  anesthesia  an  elliptic  incision  was  made  upon  the  left 
side  of  the  head,  beginning  just  in  front  of  the  ear,  and  was  carried 
up  across  the  temporal  muscle  and  down  to  the  zygoma  of  the  same 
side.  A  quarter-inch  trephine  was  used.  The  hemorrhage  was  found 
to  be  from  a  branch  of  the  middle  meningeal  artery,  and  from  within 
the  dura,  which  was  lacerated.  A  large  clot  and  much  fresh  blood 
were  lying  over  the  temporal  and  parietal  regions.  This  blood  was 
carefully  sponged  away.  The  middle  meningeal  branch  was  tied 
with  a  silk  ligature.  Gauze  wicks  were  placed  well  down  deep 
toward  the  base  of  the  skull.  The  dura  was  not  sutured.  The  bleed- 
ing vessels  of  the  diploe  were  stopped  with  wax.  The  skin  flap  was 
replaced  and  sutured,  leaving  a  small  gauze  drain  down  to  the  dura. 

The  pulse  was  poor,  and  there  was  evidence  of  considerable  shock 
at  the  conclusion  of  the  operation.  Proper  stimulation  with  strych- 
nin and  enemas  of  salt  solution  and  brandy  had  a  good  effect.  The 
temperature  rose  to  no°  F.  during  the  night,  but  dropped  immedi- 
ately and  gradually  came  to  normal. 

The  following  day  unconsciousness  was  present,  the  paralysis  was 
unrelieved,  the  breathing  was  stertorous  and  puffing. 


40 


INJURIES    TO    THE    HEAD 


The  second  day  after  the  operation  the  gauze  drain  was  removed 
and  two  smaller  gauze  drains  were  inserted.  Some  signs  of  con- 
sciousness appear.  She  takes  notice  of  people  coming  into  the 
room. 

The  fifth  day  following  the  operation  she  notices  friends.  The 
paralysis  is  still  present. 

The  sixth  day  after  the  operation  she  moves  the  right  leg  a  little. 
No  articulate  speech  is  present.  Understands  questions  and  grunts  in 
answer  to  all  questions.     She  can  express  no  idea  in  words. 

The  tenth  day  after  the  operation  she  moves  the  right  arm.  The 
mental  condition  is  clearer. 

On  the  eighteenth  day  she  moves  the  leg,  and  the  arm  has  more 

power. 

The  thirtieth  day  was  an 
important  one  for  the  patient. 
She  walked  alone  for  the  first 
time  since  the  accident. 

One  year  after  the  accident 
the  patient  is  found  to  be  hav- 
ing occasional  attacks  of  dizzi- 
ness, accompanied  by  "falling- 
fits."  She  is  perfectly  sane, 
and  talks,  often  very  well ;  then 
there  come  times  of  difficulty 
in  talking,  when  she  can  not 
find  the  right  word  to  express 
herself.  Just  after  one  of  these 
attacks  of  fainting,  etc.,  talk- 
ing is  less  easy. 

Three  years  after  the  opera- 
tion the  following  examination 
was  made  :  The  speech  is  thick, 
slow,  and  with  effort.  The  fa 
cial  muscles  of  the  left  side  are 
stiff  and  slightly  drawn  ;  they 
do  not  move  so  well  as  on  the 
right  side.  The  left  nasolabial  fold  is  more  accentuated  than  the  right. 
The  left  eyebrow  is  lower  than  the  right.  The  patient  thinks  that  she 
can  hear  better  with  the  right  ear  than  with  the  left.  The  right  hand 
gets  cold  "and  does  not  look  natural."  The  right  forefinger  is  often 
whiter  than  the  other  fingers  of  the  right  hand.  It  is  difficult  to  pick 
up  needles  or  pins  with  the  fingers  of  the  right  hand.  There  is  no 
increase  in  the  wrist-jerks.  The  knee-jerk  is  slightly  greater  on  the 
right  side  than  on  the  left. 

The  patient  says  she  is  enjoying  excellent  health,  eats  and  sleeps 
well,  and  is  out  of  doors  much  of  the  time.  She  is  taking  bromid 
of  potassium  regularly  once  a  day  in  small  doses.  About  once  a 
month  she  has  a  fainting  or  "  weak  spell."  These  attacks  are  grow- 
ing less  pronounced  and  less  frequent. 


Fig.  24. — Case  I.    Line  of  incision  shown. 


ILLUSTRATIVE    CASES 


41 


This  case  illustrates  the  important  fact  that  after  a  severe  head 
injury  with  almost  no  external  visible  sign,  the  patient  should  be  kept 
under  very  careful  observation  through  the  hours  immediately  succeed- 
ing the  accident.  Relative  symptoms  are  of  far  greater  importance 
in  head  injuries  than  isolated  observations.  Bleeding  from  the  ear  as 
a  symptom  in  head  injuries  does  not  necessarily  imply  fracture  of  the 
petrous  portion  of  the  temporal  bone.  Rupture  of  the  tympanum 
may  cause  bleeding  from  the  ear.  There  was  no  fracture  of  the  skull 
detected  after  careful  examination  in  this  case. 

The  interval  of  consciousness  in  this  case  was  a  somewhat  short 
and  hazy  one.      Immediately  after  the  accident  the  woman  was  dazed, 
and  at  no  time  was  she  herself  mentally.     It  is  to  be  remembered  in 
this    connection  that   the    interval 
of  clear  consciousness  may  be  so 
masked  by  the  symptoms  of  con- 
cussion as  to  be  completely  over- 
looked. 

Case  II. — An  open  depressed 
fracture  of  the  skull. — Absence  of 
unconsciousness. — Paralysis  of  one- 
half  of  the  body.  —  Operation. — 
Recovery. 

This  case  illustrates  that  con- 
sciousness may  be  unimpaired  fol- 
lowing an  injury  to  the  head  severe 
enough  to  cause  paralysis. 

A  boy,  nine  years  old,  was  struck 
in  the  head  by  a  brick  falling  from 
a  height.  He  was  seen  immedi- 
ately after  the  injury  and  found  to 
be  conscious.  He  answered  ques- 
tions naturally.  There  was  a  large 
scalp-wound  over  the  parietal  bone 
and  a  little  anterior  to  the  parietal 
eminence  to  the  right  of  the  median 

line.  The  bone  beneath  the  scalp-wound  was  fractured  and  depressed 
into  the  brain-substance.  The  left  arm  and  the  left  leg  were  com- 
pletely paralyzed  to  motion.  The  right  pupil  was  dilated  ;  sensation 
was  present.  The  right  upper  eyelid  dropped.  There  was  a  scar  in 
the  right  cornea.  Immediately  after  the  injury  the  temperature  was 
960  F. ,  the  pulse  was  74,  the  respiration  was  26.  When  examined 
one  hour  after  the  accident  the  pulse  had  fallen  to  68,  he  had  vomited 
once,  and  had  been  somewhat  nauseated. 

The  operation  of  elevation  of  the  depressed  fragments  of  bone 
was  done  under  ether.  The  fragments  of  bone  removed  were  about 
the  size  of  a  silver  half-dollar.  There  was  no  fissure  in  the  skull. 
The  dura  mater  was  torn  and  the  brain  slightly  lacerated.  Upon 
elevating  and  removing  the  depressed  bone  hemorrhage  occurred  from 
the  vessels  of  the  dura  mater.      The  depressed  bone  was  not  replaced. 


Fig.  25. — Case  II.  Open  depressed  frac- 
ture of  the  skull :  A",  the  mid-point  be- 
tween glabella  and  inion ;  A,  middle  of 
depressed  bone. 


42 


INJURIES    TO    THE    HEAD 


The  dura  was  left  open  and  the  cavity  was  drained  by  a  wick  of  gauze, 
which  was  removed  upon  the  third  day. 

A  few  hours  after  the  operation  the  boy  was  perfectly  conscious  as 
before  the  etherization,  the  pupils  were  normal,  and  motion  had 
returned  in  the  paralyzed  limbs. 

Three  weeks  after  the  operation  a  small,  granulating  wound  remained 
and  there  was  a  slight  tendency  to  hernia  cerebri. 

Four  months  following  the  accident  the  boy's  condition  is  as 
follows:  The  wound  is  nearly  healed  and  continues  to  discharge  at 
times.  He  walks  naturally.  There  is  no  paralysis  of  arm  or  of  leg. 
No  mental  symptom  is  present. 

The  interesting  and  unusual  fact  in  this  case  is  that  after  a  blow 
sufficiently  severe  to  cause  a  depressed  fracture  of  the  skull  and 
paralysis  of  one-half  of  the  body  the  patient  remained  conscious. 


Fig.  26. — Case  III. 


The  exact  location  of  the  injury  to  the  head  and  brain  is  shown  in 
figure  25. 

Case  III. — A  blow  upon  the  head. — Uncoiisciousness  immediate. — 
Slight  bulging  of  right  eye. — Middle  meningeal  hemorrhage. — Frac- 
ture of  skull.  —  Operation. — Recovery. 

Examination  found  edema  of  the  right  temporal  region.  Uncon- 
sciousness present.  An  interval  of  consciousness  was  absent.  Slight 
bulging  of  the  right  eye. 

Operation  in  the  right  temporal  region.  A  skin-flap  was  made  over 
the  fracture  and  edematous  area.  A  fracture  was  detected  running 
from  about  the  middle  of  the  temporal  ridge  an  inch  back  of  the 
coronal  suture  outward  and  forward  across  the  squamous  part  of  the 
temporal  bone  to  a  half-inch  behind  the  pterion. 


ILLUSTRATIVE    CASUS  43 

The  bone  anteriorly  to  the  fracture  was  depressed.  The  trephine 
was  applied  over  the  depressed  portion  behind  the  coronal  suture. 
Upon  exposing  the  dura  no  pulsation  was  seen.  The  dura  was  dark 
in  color.  A  slight  amount  of  extradural  blood  escaped.  On  follow- 
ing the  fracture  down  to  the  base  of  the  skull  the  dura  was  found 
lacerated,  the  anterior  branch  of  the  middle  meningeal  artery  was 
torn,  and  blood-clot  and  lacerated  brain-tissue  were  present.  The 
anterior  branch  of  the  middle  meningeal  artery  was  tied  and  the 
hemorrhage  ceased.  The  blood-clots  were  removed,  the  exposed  area 
was  cleansed  with  boiled  water,  and  gauze  drainage  introduced.  All 
the  gauze  was  removed  in  four  days.  No  unusual  symptoms  attended 
convalescence.     Recovery  was  complete  in  three  months  (see  Fig.  26). 

This  case  is  of  interest  because  no  fracture  was  detected  before  the 
operation,  and  it  was  supposed  that  the  bulging  of  the  eye  indicated 
an  increase  of  intracranial  pressure,  which  proved  to  be  true. 

The  method  of  operating  was  comparatively  simple,  in  that  the 
fracture  was  followed  down  until  the  bleeding  vessel  was  found.  This 
necessitated  the  free  removal  of  bone  below  the  trephine  opening. 

There  was  no  interval  of  consciousness  in  this  case,  and  the  condi- 
tions found  easily  explained  its  absence.  The  man  was  suffering  from 
concussion  and  laceration  of  the  brain  as  well  as  from  intracranial 
pressure,  and  the  interval  of  consciousness  was  obscured  by  the 
presence  of  the  concussion.  The  recognition  of  an  interval  of  con- 
sciousness is  of  very  great  importance.  If,  however,  the  interval  of 
consciousness  is  not  present,  as  in  the  case  reported,  intracranial  pres- 
sure from  hemorrhage  can  not  be  said  to  be  absent,  for  concussion 
attendant  upon  the  injury  may  mask  the  interval  of  consciousness 
which  might  have  been  present  had  the  injury  been  less  severe. 


CHAPTER  II 


FRACTURES  OF  THE  BONES  OF  THE  FACE 

FRACTURES  OF  THE  NASAL  BONES 
Anatomy. — The  anatomical  relations  of  the  nasal  bones  (to 
the  perpendicular  plate  of  the  ethmoid,  the  vomer,  the  cartil- 
aginous septum,  the  superior  maxillary  bone,  and  the  frontal  bone) 
make  their  fracture  of  far  greater  importance  than  a  mere  super- 
ficial disfigurement  of  the  face  would  indicate  (see  Fig.  27).      The 

Vertical  ethmoid  plate. 


Frontal  sinus 
Nasal  bone.   - 


Quadrilateral    - 
cartilage. 


Lower  lateral 
cartilage. 


,    Sphenoidal 
sinus. 


Vomer. 


Fig.  27. — Median  section  of  nose. 

site  of  the  fracture  is  usually  near  the  lower  edge  of  the  bone. 
Most  fractures  of  the  nasal  bone  are  open  through  either  the  skin 
or  the  mucous  membrane.  In  nearly  all  nasal  fractures  the  carti- 
lage of  the  septum  is  more  or  less  injured.  The  upper  lateral  car- 
tilages may  be  torn  from  their  attachments  to  the  nasal  bones, 
simulating  fracture  of  these  bones.  The  resulting  deformity  of 
this  accident  is  well  illustrated  in  figure  2<S.  A  high  fracture  of 
the  nasal  bones  with  lateral  deformity  is  shown  in  figure  30  :  the 
nasal   bone  of  one  side  has  been  impacted  with  the  frontal  bone, 

44 


FRACTURES    OF    THE    NASAL    BONES 


45 


rr 

VB\       a 

1 

^■^■W.- 

■ftafc 

CN* 

■^8 

Fig.  28. — Separation  of  cartilage  from  nasal 
bones  (Harrington). 


Fig.  29.— Fracture  and   lateral  displace- 
ment of  each  nasal  bone. 


Fig.  30. — Case  of  fracture  of  nasal  bones. 
Lateral  displacement  (Harrington). 


Fig.  31. — Fracture  and  lateral  displace- 
ment of  each  nasal  bone.  Side  view  ot 
figure  29. 


46 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


and  the  nasofrontal  articulation  upon  the  opposite  side  has  been 
separated.  Figures  29  and  31  show  a  case  in  which,  by  a  direct 
blow  squarely  upon  the  nasal  bones,  the  bones  were  separated 
and  one  was  laid  on  one  nasal  process  of  the  superior  maxillary 
bone  and  the  other  was  laid  upon  the  corresponding  bone.  The 
septum  was  intact,  as  is  shown  by  the  persistence  of  the  natural 
position  of  the  tip  of  the  nose.  Figures  32  and  33  show  a 
syphilitic  nose,  the  septum  gone,  and  the  nose  fallen  in.  The 
contrast  in  these  two  cases  is  instructive. 


Fig.  32.— Syphilitic  deformity  (Harrington).        Fig.  33.— Syphilitic  deformity  (same  case  as  Fig.  32). 


Symptoms. — Pain,  swelling,  crepitus,  and  deformity  are  usu- 
ally present.  The  subcutaneous  swelling  is  often  so  considerable 
as  to  obscure  deformity.  Gentle  pressure  is  often  sufficient  to 
detect  crepitus  in  this  fracture,  when  a  firm  grasp  determines 
little  or  nothing. 

Complications. — Through  infection  of  the  internal  or  the 
external  wounds  suppuration  begins,  abscesses  form,  and  necrosis 
of  bone  and  liquefaction  of  cartilage  may  occur.  Emphysema 
may  be  noticed  if  the  fracture  is  open   into  the  nasal  cavity  (see 


THE  NASAL  SEPTUM  IN  FRACTURE  OF  THE  NOSE 


47 


Fig.  34).  It  will  disappear  after  a  few  days  untreated.  The 
lachrymal  duct  may  be  obstructed  if  the  nasal  process  of  the 
superior  maxillary  bone  is  involved.  The  nasal  bone  may  be 
forced  up  into  the  floor  of  the  anterior  fossa  of  the  skull,  and 
cerebral  complications  arise  (see  Fig.  16).  If  the  deformity  fol- 
lowing fracture  of  the  nasal  bones  is  not  corrected,  there  is  great 


Fig.  34.— Case  of  open  fracture  of  the  nasal  bones.     Emphysema  over  the  forehead  and  the 

upper  part  of  the  face. 


likelihood  of  trouble,  either  immediately  or  in  after  years,  because 
of  damage  to  the  nasal  septum. 

The  Nasal  Septum  in  Fracture  of  the  Nose  (see  Figs.  35, 
3^,  37»  38,  39)- — The  starting  of  the  quadrilateral  cartilage  of 
the  septum  at  some  of  its  bony  attachments  may  be  evident  at 
once  after  the  fracture  of  the  nose  as  a  marked  dislocation,  or  no 
change  may  be  seen  until  long  afterward,  when  a  ridge  due  to 
inflammatory  thickening  is  found  along  the  previously  loosened 


48  FRACTURES  OF  THE  BONES  OF  THE  FACE 

border.  The  septum  may  be  dislocated  from  its  attachment  to 
the  superior  maxilla,  and  deviate  into  one  nostril  or  the  other  like 
a  curtain.  The  commonest  dislocation  occurs  at  the  junction  of 
the  cartilage  of  the  septum  with  the  vomer  and  the  ethmoid. 

Lesions  of  the  septum  due  to  fracture  occur  usually  in  the  pos- 
terior two-thirds  of  the  cartilaginous  and  in  the  anterior  half  of  the 
bony  septum.  Fractures  rarely  extend  through  the  septum  to 
the  posterior  nares.  In  fractures  of  the  nasal  bones  with  little 
displacement  the  septum  may  show  no  changes.  Even  with 
considerable  depression  and  comminution  of  the  nasal  bones,  the 
septum  as  a  whole  may  appear  unchanged,  the  lesions  of  the 
septum  being  confined  to  bowing  or  tearing  at  the  seat  of  frac- 
ture. When  the  nasal  bones  are  much  deviated,  the  free  edge  of 
the  septum  deviates  with  them.      Fractures  of  the  nasal  bones 


Fig.  35-  F'K-  36.  Fig.  37.  Fig.  3S.  Fij 

Figs.  35-39. — The  septum  in  fractures  of  the  nose  (Mosher). 


may  occur  alone  or  in  combination  with  fractures  of  the  septum. 
Severe  cases  of  broken  nose  usually  combine  the  two  conditions. 
Fractures  of  the  septum  which  admit  of  classification  follow  one  of 
two  types — horizontal  fractures  or  vertical  fractures.  The  vertical 
fracture  is  much  the  rarer.  It  may  occur  anywhere  in  the  course 
of  the  cartilaginous  septum,  but  when  situated  well  back,  is  to  be 
distinguished  from  dislocation  of  the  cartilage.  The  horizontal 
fracture  produces  a  gutter-like  deformity  roughly  parallel  with 
the  floor  of  the  nose.  The  convexity  appears  in  one  naris,  the 
concavity  in  the  other.  Closely  allied  to  these  last  two  fractures 
are  the  sigmoid  deviations,  in  which  the  relation  to  fracture  is 
unsettled.  They  are  so  common  that  the)'  are  mentioned  for  the 
sake  of  completeness.  The  name  describes  them.  They  occur 
in  the  same  two  types  as  the  angular  variety. 


THE    NASAL    SEPTUM    IN    FRACTURE    OF    THE    NOSE 


49 


Treatment. — The  nasal  cavity  should  be  inspected  by  mirror 
and  light  to  determine  any  lesion  of  the  septum.  Cocain  anes- 
thesia is  necessary  for  this  examination.  If  a  deviation  is  found, 
it  should  be  corrected  along  with  the  correction  of  the  external 
nasal  deformity.  For  this,  primary  anesthesia  will  be  needed,  as 
the  manipulation  is  extremely  painful.  By  external  manipulation 
combined  with  elevation  of  the  fragments  and  internal  pressure 
with  Roe 's  elevator  (see  Fig.  40)  the  deformity  usually  can  be 
overcome.  Any  strong,  narrow,  and  thin  instrument  will  be  of 
service  as  an  elevator.     For  fractures  high  up  with  displacement, 


Fig.  40. — Fracture  of  nasal  bones.     Elevation  of  depressed  bone  by  instrument  introduced 

into  the  nostril. 


gauze  packing  carried  well  up  will  be  required  to  retain  the  ele- 
vated bones.  For  lower  deviations  the  Asch  tube  will  be  needed. 
If  the  nose  is  crushed,  it  will  be  necessary  to  model  the  nose  over 
the  Asch  tube,  one  being  placed  in  each  nostril  to  preserve  the  con- 
tour and  lumen  of  the  nose.  If  there  is  no  tendency  for  the  de- 
formity to  recur,  the  use  of  splints  is  not  indicated.  Care  must 
be  exercised  to  avoid  sudden  pressure  on  the  nose  from  the  rough 
use  of  the  pocket  handkerchief.  In  the  treatment  of  these  cases 
special  cleanliness,  perfect  drainage,  and  frequent  dressings  are  im- 
portant. If  there  is  a  recurrence  of  the  external  deformity,  localized 
4 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


pressure  may  be  exerted  in  various  ways,  all  of  which  are  more 
or  less  unsatisfactory. 

The  tin  splint  fixed  to  the  forehead  by  a  circular  plaster  band 
is  of  service.  This  tin  splint  (see  Fig.  41),  made  from  ordinary 
sheet  tin,  consists  of  a  forehead  and  a  nasal  portion.  The  nasal 
portion  may  be  twisted  or  bent  laterally  to  secure  the  desired 
pressure  upon  the  nose,  the  counterpressure  being  obtained 
through  the  fixation  secured  by  the  adhesive  plaster  band. 
Repeated  adjustments  of  this  splint  are  needed  to  make  the 
splint  of  continued  efficiency  ;  with  all  care, 
however,  the  tin  splint  is  not  generally  effec- 
tive. 

The  use  of  adhesive  plaster  strips  (after 
Davis)  from  cheek  or  malar  bone  to  nose 
with  small  compresses  is  of  limited  value. 
Cobb's  nasal  splint,  shown  in  figure  42, 
is  expensive,  but  is  very  satisfactory  for 
making  direct  pressure  upon  the  nasal 
bones.  The  splint  is  made  of  a  band  ol 
steel,  fitted  to  the  head  like  the  hat-band  of 
a  hat.  To  this  band  are  attached  an  arm  and 
a  pad  with  screw  adjustment.  A  strap  over 
the  head  and  one  beneath  the  chin  prevent 
downward  and  upward  displacement. 

Coolidge's  Splint  (see  Fig.  43). — This 
consists  of  a  tin  pad  for  the  forehead  with 
strap  encircling  the  forehead  for  the  retention  of  the  pad  in  posi- 
tion. To  the  lower  border  of  the  pad  arc  soldered  two  wire 
arms  upon  which  slide  two  small  felt  pads.  The  arms  can  be 
bent  so  that  counterpressure  may  be  obtained  upon  the  firm 
parts  of  the  face,  while  direct  pressure  with  the  other  pad  is 
brought  to  bear  upon  the  nose.  This  splint  is  inexpensive  and 
is  efficient. 

Th'-  nasal  cavity  should  be  idealised  at  least  twice  daily  with 
antiseptic  douches.  Seller's  tablets,  one  tablet  dissolved  in  a 
quarter  of  a  tumbler  <>f  warm  water,  used  with  the  Birmingham 
-las-  douche,  make  a  satisfactory  wash.  The  external  wounds 
should  be  dressed  according  to  general  surgical  principles.       It  is 


Fig.  1 1 .  —  Fracture  <>i 
nasal  bones.  Tin  nose- 
splint  applied. 


THE    NASAL    SEPTUM     IN    FRACTL'Kl".    ()l 


UK    NOSE 


51 


well  to  remember  in  this  connection  that  suppurating  wounds  do 
far  better  if  dressed  frequently  than  if  left  to  accumulate  purulent 
discharges. 

After  a  blow  upon  the  nose,  even  if  there  is  no  immediate  de- 
formity, the  nose  should  be  examined  to  determine  the  presence 
of  swelling-  upon  the  cartilaginous  septum.  Even  a  slight  blow 
upon  the  nose  may  cause  a  hematoma  of  the  cartilaginous  septum 
(see  Fig.  44).  This  hematoma  is  liable  to  become  infected  and 
to  suppurate.  Considerable  destruction  of  cartilage  may  follow, 
resulting-  in  marked  disfigurement  of  the  nose. 


Fig.  42. — Cobb's  splint  applied  to  a  case  of  fracture  of  the  nose.    The  head-band  is  so  adapted 
to  the  shape  of  the  head  that  it  remains  fixed  and  offers  a  point  of  counterpressure. 


The  involvement  of  the  base  of  the  skull  adds  a  serious  ele- 
ment to  an  ordinary  simple  accident  (see  Figs.  16,  18). 

The  prognosis  as  regards  the  resulting  deformity  must  always 
be  guarded.  Union  usually  takes  place  within  two  weeks  of  the 
accident  and  is  firm  in  one  month.  In  treating  fracture  of  the 
nose  it  is  important  to  be  ever  mindful  of  hematoma  of  the  septum, 
and  abscess  of  the  septum  resulting  from  it.  The  external  de- 
formity that  follows  fracture  does  not  tend  to  increase,  but  the 
internal  deformity  does.  It  is,  therefore,  of  even  more  impor- 
tance to  correct  the  internal  deformity  than  the  external.  Unless 
both  are  corrected,  the  nose  may  be  straight  but  obstructed. 


52 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


FRACTURES  OF  THE  MALAR  BONE 
Examination. — Palpation   of   the    malar    bone    is   somewhat 
difficult.      The  best  method  of  doing  it  is  to  stand  behind  the 
sitting  patient  (see  Fig.  45),  and  to  feel  both  malar  bones  at  the 


F'g-  43- — Coolidge's  nasal  splint :  a,  Forehead  plate;  b,  pad  ;  c,  screw  controlling  position  of 

pad  ;  d,  head-strap. 


Fig.  44. — Hematoma  of  the  nasal  septum  (after  Roe). 


same  time — the  left  one  with  the  left  hand,  the  right  one  with 
the  right  hand.  The  malar  process  of  the  superior  maxilla  is 
felt  inferior]}-  by  pushing  the  skin  of  the  check  upward.  The 
orbital  part  of  this  process  is  felt  superiorly  at  the  middle  of  the 


FRACTURES    OF    THE    MALAR    BONE 


53 


inferior  border  of  the  orbit.  Following  the  orbital  margin  out- 
ward and  upward,  the  orbital  border  is  palpated  up  to  the  frontal 
process.  Following  the  malar  process  of  the  superior  maxilla 
backward,  the  free  inferior  border  of  the  malar  is  felt  continuous 
backward  with  the  zygomatic  process.  Starting  on  the  frontal 
process,  the  posterior  border  of  the  malar  may  be  palpated  down- 
ward and  backward  to  the  upper  border  of  the  zygomatic  process 
of  the  temporal  bone.  The  inferior  surface  of  the  malar  may  be 
felt  by  placing  the  fingers,  palm  upward,  in  the  superior  sulcus 
of  the  cheek  and  following  backward  until  the  coronoid  process 
of  the  lower  jaw  is  felt.      In  the  case  of  a  fracture  that  is  as  often 


Fig.  45.— Proper  position  from  which  to  palpate  the  malar  bones.     The  fingers  touch  the 
inferior  borders,  the  thumbs  the  posterior  borders,  of  the  malar  bones. 


unrecognized  as  is  this  one  it  is  important  to  be  very  familiar  with 
the  details  of  the  outline  of  the  bone. 

Symptoms. — Fracture  of  the  malar  bone  is  caused  by  a  severe 
blow  upon  the  cheek.  It  is  rather  unusual  to  find  a  fracture  of 
the  body  of  the  bone.  More  often  there  is  a  fracture  of  one  of  its 
processes,  the  line  of  fracture  being  continuous  with  a  fracture  of 
some  adjoining  bone.  The  malar  is  depressed  as  a  whole,  or  tilted 
inward  toward  the  zygomatic  fossa  because  of  a  loosening  of  One 
or  more  of  its  articulations  or  because  of  a  fracture  or  crushing 
of  the  superior  maxilla.  The  deformity  consists  of  a  depression 
to  the  outer  side  of  and  below  the  eye.  The  line  of  fracture  or 
separation  can  sometimes  be  palpated.  Mobility  and  crepitus 
are  rarely  obtained.      If  the  depression  of  the  malar  or  of  an  asso- 


54 


FRACTURES  OF  THE  HONES  OF  THE  FACE 


dated  fracture  of  the  zygomatic  arch  impinges  upon  the  space  in 
which  the  coronoid  process  moves  in  the  opening  of  the  mouth, 
the  motions  of  the  lower  jaw  will  be  restricted  (see  Fig.  46). 
The  limitation  of  motion  of  the  lower  jaw  may  be  temporary  or 
permanent,  depending  upon  whether  it  is  due  to  hemorrhage 
and  swelling  or  bony  pressure.  The  coronoid  process  of  the 
lower  jaw  may  be  fractured  by  the  same  force  which  fractured 
the  zygoma  or  malar.  Localized  subconjunctival  hemorrhage 
may  appear  if  the  orbit  is  involved.  If  the  floor  of  the  orbit  is 
fractured  so  that  the  infra-orbital  nerve  is  implicated,  there  will 
appear  prickling  sensations  throughout  the  area  of  distribution 


Fig.  46. — Note  relations  of  coronoid  of  inferior  maxilla  to  zygomatic  process  and  malar  bones. 


of  that  nerve — namely,  along  the   upper  gum,  the  skin   of  the 
cheek,  of  the  nose,  and  of  the  upper  lip. 

Treatment. — It  is  oftentimes  impossible  completely  to  correct 
the  deformity  except  by  operative  means.  If  any  interference  with 
the  movements  of  the  lower  jaw  persists  after  the  acute  swelling 
disappears, — that  is,  after  two  weeks, — or  if  it  is  very  evident  at 
the  outset  that  the  limitation  of  motion  is  due  to  the  depression 
of  bone,  then  operative  interference  is  demanded.  Before  a  cut- 
ting operation  is  resorted  to  an  anesthetic  should  be  administered 
and  an  attempt  made  by  pressure  with  a  blunt  instrument  under 


FRACTURES    OF    THE    SUPERIOR    MAXILLA  55 

the  malar  from  inside  the  cheek  to  raise  the  depressed  fragment. 
If  this  can  not  be  effected,  a  small  incision  should  be  made  at 
the  most  advantageous  point,  avoiding  making  the  fracture  an 
open  one.  Through  this  incision  access  is  gained  directly  to 
the  bone.  By  means  of  a  narrow  periosteum  elevator,  retractor, 
hook,  or  a  screw  elevator,  the  fragment  can  be  raised  into  its 
normal  position. 

Union  occurs  in  two  weeks.  There  is  no  tendency  to  a 
recurrence  of  deformity,  therefore  no  retentive  apparatus  is 
necessary. 

The  surgeon  is  not  uncommonly  asked  to  remove  the  slight 
depression  attending  a  healed  fracture  of  the  malar  bone.  This 
may  be  most  difficult.  It  should  be  attempted,  however,  as  in 
fresh  injuries,  without  a  cutting  operation,  or  by  an  incision 
within  the  mouth  through  the  mucous  membrane,  or,  if  neces- 
sary, by  an  external  incision. 


FRACTURES  OF  THE  SUPERIOR  MAXILLA 
Fracture  of  the  superior  maxilla  occurs  so  frequently  from  a 
bicycle  injury  that  it  may  properly  be  called  the  bicycle  accident. 
The  blow  causing  this  fracture  is  usually  not  in  the  direction  to 
damage  the  base  of  the  skull,  but  to  tear  the  bones  of  the  face. 
The  nasal  process  of  the  superior  maxilla  may  be  broken  when 
the  nasal  bone  is  fractured.  The  anterior  wall  of  the  antrum 
may  be  broken  by  the  same  blow.  The  alveolar  process  may  be 
broken.  The  damage  to  the  bones  of  the  face,  and  particularly 
to  the  upper  jaw,  is  associated  with  injuries  to  various  con- 
tiguous bones.  Blows  result  in  many  irregularly  disposed  frac- 
tures. 

The  diagnosis  is  made  by  inspecting  the  mouth,  nose,  and 
cheek.  These  fractures  being  open,  there  is  little  difficulty 
in  detecting  them.  A  very  careful  inspection  should  be  made, 
with  an  anesthetic  if  necessary,  to  determine  the  extent  of  the 
lesions.  Emphysema  and  great  swelling  of  the  face  occur. 
There  may  be  no  wound  of  the  skin.  Whether  the  injury  to  the 
upper  jaw  is  associated  with  injury  to  the  base  of  the  skull  or 
not  can  be  determined  in   the  absence  of  visible   signs   bv   the 


56  FRACTURES  OF  THE  BONES  OF  THE  FACE 

subsequent  development  of  cerebral  symptoms.  Necrosis  of  bits 
of  bone  is  rare  after  upper-jaw  fractures,  excepting  fracture  of 
the  alveolar  border.  Hemorrhage  may  be  considerable,  but  it  is 
easily  controlled  by  pressure.  The  infra-orbital  nerve  may  be 
damaged.  The  lachrymal  canal  may  be  temporarily  compressed 
or  obliterated. 

Treatment. — If  there  is  no  wound  of  the  skin  and  much 
depression  of  the  jaw,  so  that  the  face  looks  knocked  in,  it  will 
be  necessary  to  devise  some  method  of  elevating  the  depressed 
bone  and  of  restoring  the  normal  contour  of  the  face.  To  avoid 
a  visible  scar,  the  mucous  membrane  should  be  incised  on  the 
inner  side  of  the  upper  lip,  and  the  fragments  elevated  by  an 
instrument  introduced  through  the  incision.  As  little  bone  as 
possible  should  be  removed,  so  as  to  leave  sufficient  support  to 
the  soft  parts  of  the  cheek  after  healing.  Only  thus  can  a  fall- 
ing in  of  the  cheek  be  prevented.  If  access  through  the  mouth 
is  unsuccessful,  it  may  be  necessary  to  incise  the  skin  over  the 
fracture.  This,  of  course,  is  to  be  avoided  if  possible.  The 
accidental  wounds  should  be  thoroughly  and  vigorously  swabbed 
with  a  solution  of  corrosive  sublimate  (i  :  5000).  The  use  of 
tiny  swabs  of  gauze  held  by  forceps  will  facilitate  this  procedure. 
The  avoidance  of  sepsis  in  these  cases  is  of  paramount  impor- 
tance. If  the  wounds  become  septic,  there  is  great  danger  of  an 
extension  of  the  inflammatory  process  to  the  deeper  parts  or 
even  to  the  meninges  of  the  brain.  Lacerations  of  the  soft  parts — 
lips  and  cheeks — may  have  their  edges  approximated  to  secure  less 
scar  than  if  left  unsutured.  Loose  small  bits  of  bone  should  be 
removed  with  forceps  and  scissors.  Loosened  teeth  should  be  left 
in  good  position  in  their  sockets.  A  mold  of  the  lower  jaw  should 
be  taken  in  composition  or  plaster-of- Paris,  if  possible,  by  a  com- 
petent dentist,  and  a  rubber  splint  made  from  this  mold  to  fit 
the  teeth  and  alveolar  border  of  the  lower  jaw.  When  this 
splint  is  applied,  its  upper  surface  may  be  brought  up  against  the 
teeth  of  the  upper  jaw  and  held  snugly  in  apposition  by  an 
external  bandage,  as  in  fracture  of  the  lower  jaw.  This  splint 
will  materially  assist  in  reducing  the  displacement  of  the  upper- 
jaw  fragments.  It  may  be  possible  for  a  dentist  to  apply  a  splint 
directly  to  the  alveolar  margin  and  teeth  of  the  upper  jaw.     If 


FRACTURES    OF    THE    SUPERIOR    MAXILLA  57 

this  is  possible,  greater  security  of  fragments  will  be  obtained 
than  by  any  other  method  of  treatment.  The  physician  may 
greatly  assist  in  immobilizing  the  fracture,  until  a  permanent 
dressing  is  applied,  by  making  quickly  a  temporary  splint  of 
dental  wax  or  dental  composition,  and  applying  it  to  the  teeth  and 
alveolar  margin  of  the  upper  jaw.  This  composition  is  softened 
and  made  malleable  by  placing  it  in  hot  water  ;  it  can  then  be 
molded  on  the  jaw,  and  in  two  or  three  minutes  is  firm  (see 
Fracture  of  the  Lower  Jaw). 

After  Care. — Six  weeks  to  two  months  will  be  necessary  to 
insure  firm  union  and  freedom  from  complications.  The  swell- 
ing associated  with  the  reparative  process  will  gradually  subside. 
Great  care  must  be  exercised  in  the  nursing  of  the  patient  after 
this  injury,  as  the  element  of  shock  is  an  important  one  to  be 
considered.  Strychnin  sulphate  (^  of  a  grain),  given  two  or 
three  times  daily,  is  indicated  if  there  is  evidence  of  shock  follow- 
ing the  accident.  This  should  be  continued  each  day  for  as  long 
a  period  as  shock  is  evident. 

Proper  nourishment  under  these  adverse  conditions  of  adminis- 
tration is  to  be  given  careful  consideration.  Liquids  alone  are 
to  be  used  the  first  week.  These  may  be  given  by  enemata 
or  by  the  mouth  with  a  tube  to  the  back  of  the  pharynx  or 
by  a  nasal  tube  if  necessary.  Nasal  feeding  is  simply  and  easily 
carried  out.  A  rubber  tube  three  feet  long  is  needed,  to  one 
end  of  which  is  attached  a  funnel  and  to  the  other  end  a  soft- 
rubber  catheter,  in  size  No.  io  F.  The  patient  is  half  reclining 
while  the  surgeon  introduces  the  catheter  into  the  nose  until  it 
passes  well  back  and  down  into  the  pharynx.  The  funnel,  some- 
what elevated  a  foot  or  more  above  the  patient's  head,  is  kept 
filled  with  the  liquid  nourishment  so  that  its  contents  run  slowly 
into  the  esophagus.  A  plug  of  absorbent  cotton,  moistened  with 
a  four  per  cent,  cocain  solution,  and  placed  in  the  nose  for  a  few 
minutes  before  feeding,  facilitates  this  procedure. 

The  nose  and  mouth  should  be  douched  and  swabbed  regu- 
larly each  day.  This  should  be  done  after  feeding  the  patient, 
and  oftener  if  necessary  in  order  to  avoid  all  odor  from  the 
mouth.  Listerin,  two  teaspoonfuls  to  half  a  cup  of  water,  is  a 
satisfactory  wash  for   this  purpose.     The  profuse    dribbling   of 


58 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


saliva  which  attends  this  fracture  demands  drainage  of  the  mouth 
by  wicks  of  gauze  placed  in  the  cheeks  and  gauze  handkerchiefs 
for  keeping  the  surrounding  parts  dry.  Wiring  the  fragments  of 
bone  may  be  necessary  if  there  is  great  displacement.  Wiring 
the  alveolar  border  to  the  body  of  the  jaw  may  be  demanded. 
Suture  of  the  bony  fragments  with  chromicized  catgut  will  often 
steady  them  in  position  until  union  takes  place. 

FRACTURES  OF  THE  INFERIOR  MAXILLA 
With   the   exception   of  the   superior  internal    surface   of  the 
articular  process,  practically  the  whole   of  the  inferior  maxilla 
may  be  palpated.      Fractures  of  the  inferior  maxilla  are  caused 


Fig.  47. — Fracture  of  the  inferior  maxilla 
(interdental  splint)  (X-ray  tracing). 


Fit;.  (8.— Fracture  of  the  inferior  max- 
illa in  two  places.  Alinement  of  teeth  per- 
fect (X-ray  tracing). 


by  direct  violence.  The  seat  of  the  fracture  will  be  deter- 
mined by  the  force  and  direction  of  the  blow,  by  the  location 
of  the  teeth  in  the  jaw  (the  jaw  being  weakest  where  the  teeth 
have  been  lost),  by  the  presence  of  any  foreign  body  between 
the  teeth  (such  as  a  pipe),  and  by  the  presence  or  absence  of 
muscular  relaxation.  Fractures  of  the  base  of  the  skull 
through  blows  on  the  jaw  are  more  likely  to  occur  if  the  mouth 
is  open.  Fractures  of  the  bod)'  of  the  bone  are  common;  of 
the    ramus   behind   the   molar   teeth,  rather   uncommon  ;    of  the 


FRACTURES    OK    THE    INFERIOR    -MAXILLA 


59 


condyloid  and  coronoid  processes,  very  uncommon.      The  seats 
of  fracture  of  the  inferior  maxilla  are  shown 
in  the  accompanying  illustrations  (see  Figs. 
47,  48,  49,  50). 

Excepting  those  of  the  condyloid  and 
coronoid  processes,  fractures  of  the  inferior 
maxilla  almost  always  open  into  the  mouth. 
They  occasionally  open  through  both  the 
mucous  membrane  and  the  skin. 

Examination. — Even  when  the  patient 
can  not  open  the  mouth  sufficiently  to  admit      the  ^ner4sideofrtheafveo- 

, ,  .     .  r  1       l-  c  ^1        i_       1  lar   process,   from    a   force 

the  examining  ringer,  palpation  of  the  body      applied  to  teeth. 

and  ramus   of  the  jaw,  with   one  finger  in 

the  cheek  and  another  finger  upon  the  chin,  will  often  reveal  the 

seat  of  fracture. 

Symptoms. — Pain,  crepitus,  and  abnormal  mobility  may  be 


Fig.  50. — Fracture  of  the  lower  jaw,  showing  loss  ot  aliiiement  of  teeth. 


present.  Immediate  swelling  of  the  gum  appears  at  the  seat  of 
the  fracture.  Teeth  contiguous  to  the  fracture  of  the  body  of 
the  maxilla  will  be  either  displaced  or  loosened.      The  displace- 


6o 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


ment  of  the  fragments  in  fracture  of  the  body  and  ramus  will  be 
most  easily  detected  by  noticing  the  differences  in  level  of  the 
teeth  on  each  side  of  the  fracture  (see  Fig.  50).  The  face 
appears  swollen.  After  a  few  days  the  submaxillary  and  adjoin- 
ing cervical  lymphatic  glands  become  enlarged.  The  salivary 
secretions  are  increased  in  quantity,  and  because  of  the  disincli- 
nation to  painful  swallowing,  the  saliva  dribbles  out  of  the  mouth. 
If  the  fracture  opens  into  the  mouth,  suppuration  often  appears 
and  pus  mingles  with  the  saliva.  Particles  of  decomposing 
food    between    the    teeth    and    in    the   spaces    outside   the   jaw 


Fig.   51.— Aluminium  splint  to  be  placed  in  teeth.     For  closed  fracture,  a  continuous  capping 
of  gold  or  aluminium  or  other  metal  cemented  upon  the  teeth. 


within  the  cheeks  add  to  the  bacterial  pabulum.  The  odor  from 
this  mass  of  foul  material  is  characteristically  penetrating  and 
offensive.  After  a  few  weeks  necrosis  of  bone  may  occur  at 
the  seat  of  fracture,  with  abscess  formation.  A  discharging 
sinus  pointing  to  the  disease  appears.  These  cervical  abscess--, 
often  difficult  to  manage,  occupy  the  region  of  the  body  of 
the  jaw.  The  submaxillary  and  upper  carotid  triangles  may 
be  filled  by  a  brawny  infiltration  associated  with  necrosis  of  a 
fractured  jaw.  On  the  otlier  hand,  with  proper  treatment  and  in 
less  difficult  cases  the  course  of  the  healing  process  is  simple 
and   of    easy    management.      Suppuration    is    prevented.      There 


FRACTURE    OF    THE    BODY    OF    THE    JAW 


6l 


is    no  necrosis,  and    the    repair  of  the  fracture  takes  place  un- 
hindered. 

Treatment. — The  primary  object  of  treatment  is  the  preser- 
vation of  the  natural  alinement  of  the  teeth.  This  object  is 
attained  by  a  complete  reduction  of  the  fragments  of  the  frac- 
tured bone.  If  a  tooth  interferes  with  the  perfectly  accurate 
closure  of  the  mouth,  and  if  the  adjustment  of  the  fragments  is 
prevented  by  the  position  of  the  tooth,  it  should  be  extracted  at 
once.  Ordinarily,  there  is  but  slight  displacement.  This  dis- 
placement can  be  corrected  by  digital  pressure  upon  both  frag- 
ments. 


Fig.  52. — Four-tailed  bandage  for  fractured  jaw. 


Fracture  of  the  Body  of  the  Jaw. — The  simple  fracture  of 
the  body  of  the  jaw  without  much  displacement  may  be  tem- 
porarily treated  by  the  four-tailed  bandage,  which  should  hold 
the  teeth  of  the  lower  jaw  closely  in  apposition  with  the  corre- 
sponding teeth  of  the  unbroken  upper  jaw.  As  soon  as  prac- 
ticable, a  dental  splint  of  rubber  or  aluminium  should  be  made 
and  applied  by  a  dentist.  This  aluminium  splint  fits  the  crowns 
of  the  teeth  some  distance  upon  each  side  of  the  fracture, 
and  holds  the  fragments  firmly  in  apposition  (see  Fig.  51).  It 
also  permits  of  opening  and  shutting  the  mouth.      The  old-time 


62 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


four-tailed  bandage  and  extradental  splint  of  millboard  (see 
Fig.  52)  is  inefficient.  As  a  permanent  dressing  it  should  be 
discarded.  It  is  useful  only  as  a  temporary  support.  In  the 
simple  cases,  in  the  absence  of  a  competent  dentist  to  make  the 
aluminium  or  rubber  dental  splint,  a  splint  of  silver  wire  passed 
around  many  teeth  upon  each  side  of  the  seat  of  fracture  is 
often  efficient.  The  method  of  wiring  two  adjoining  teeth,  those 
on  each    side  the  fracture,   is   unsatisfactory  in   that   the   strain 


Fig.  53. — Fracture  of  the  lower  jaw.     Wiring  with  silver  wire. 


loosens  the  teeth   and  displacement  is    easily  effected  (sec    Fig. 

53)- 

Fracture  of  the  body  toward  the  angle  of  the  jaw,  through  the 

region  of  the  molar  teeth,  is  often  less  easily  held  in  good  posi- 
tion. To  the  dental  rubber  splint  the  dentist  should  add  lateral 
arms  of  wire,  held  in  position  by  a  posterior  strap  (see  Fig.  54). 
These  wire  arms  increase  the  efficiency  of  the  dental  splint,  tor  a 
bandage  is   passed   under  the  chin   between   the  wires  and   thus 


FRACTURE    OF    THE    BODY    OF    THE    |A\V 


63 


Fig.  54. — Hard-rubber  splint,  with  arms  and  posterior  strap. 


E'S-  55- — Hard-rubber  splint,  with  arms  and  bandage,  applied.   Similar  to  figure  5.1  ( Moriarty). 


64  FRACTURES  OF  THE  HONES  OF  THE  FACE 


pjK_  56.— Hard-rubber  splint;  wire  arms  and  chin-piece  held  together  by  metal  rods  and  nuts. 


Fig.  57.— Same  splint  as  seen  in  figure  56;  superior  vii  w. 


FRACTURE    OF    THE    BODY    OF    THE    JAW 


65 


Fig.  58. — Front  view  of  splint  (figure  56),  with  mouth  closed  (Moriarty). 


Fig.  59. — Side  view  of  splint  (figure  56)  ;  arms  and  chin-piece  in  position  (Moriarty ). 


66 


FRACTURES  OF  THE  BOXES  OF  THE  FACE 


steadies  the  jaw  by  upward  pressure  (see  Fig.  55).  If  a  still 
more  efficient  method  is  demanded,  the  dentist  uses  an  extra- 
dental  chin-piece  of  metal  (see  Fig.  56),  which  is  adjusted  by 
screws  so  that  firm,  evenly  graduated  pressure  upon  the  fractured 
jaw  is  maintained  between  the  inside  dental  splint  and  the  out- 
side chin-piece.  While  wearing  this  splint  the  mouth  can  be 
opened  easily  (see  Figs.  58,  59,  60). 

The    Making  of  the  Dental   Splint. — If  an  impression  is  de- 


Fig.  60. — Splint  similar  to  figure  56.    Mouth  maybe  opened  without  impairing  efficiency  ot 

splint  (Moriarty). 


sired  of  the  crowns  of  the  teeth  and  the  adjoining  gum,  it  is  best 
made  by  using  the  modeling  composition  manufactured  for  the  use 
of  dentists.  The  necessary  amount  of  the  composition  is  dropped 
into  hot  water  ;  when  soft,  the  composition  is  put  into  the  metal 
impression-cups  (see  Fig.  61).  The  surface  of  the  composition  is 
warmed  by  holding  it  over  a  flame  or  holding  it  again  in  hot  water  ; 
then  the  impression-cup  containing  the  softened  composition  is 
placed  in  the  mouth  and  the  impression  made.  Immediately  upon 
tin-  removal  of  the  mold   from  the  mouth  the  composition  cools 


THE    MAKING    or    THE    DENTAL    SPLINT 


67 


and  hardens.  From  this  mold  is  made  the  duplicate  of  tin- 
alveolar  border  and  the  teeth  in  plaster-of-Paris  (see  Fig.  62). 
The  lines  of  fracture  are  clearly  indicated  upon  the  plaster  cast. 


Fig.  61. — Modeling  cups:  A,  Used  for  the  upper  jaw  ;  B,  used  for  the  lower  jaw. 

With  a  fine  saw  the  cast  is  cut  upon  these  lines  and  the  lower 
teeth  are  articulated  with  the  plaster  cast  of  the  upper  jaw,  which 
has  been  made.      Plaster  cream  is  used  to  hold  the  sawed  por- 


Fig.  62. — Plaster  cast  of  fracture  of  the  Fig.  63. — Plaster  cast  of  lower  jaw  articu- 

jaw.  lating  with  upper  jaw. 


tions  together.  In  other  words,  the  fracture  has  been  repro- 
duced and  reduced  in  plaster-of-Paris.  Both  upper  and  lower 
casts  are  then  put  upon  an  articulator  (see  Fig.  63).    A  vulcanite 


68 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


splint  is  made  from  this  reconstructed  lower  jaw,  and  when  this  is 
applied  to  the  fractured  jaw  as  an  interdental  splint,  the  deformity 


Fig.  64. — Simple  vulcanite  splint,  with  boxes  vulcanized  on  each  side  (Moriarty). 

is  corrected  and  comfortably  prevented  from  recurring  (see  Figs. 
64,  65). 


.— 1  lard-rubber  splint  in  position,  uppei  teeth  resting  upon  it  1  Moriarty  1. 


Fracture  of   the  Ramus  of   the  Inferior  Maxilla  Just  Behind 
the  Molar  Teeth. — The  displacement  is  difficult  to  correct.     The 


TREATMENT 


69 


fracture  is  usually  oblique  from  before  backward  and  downward, 
as  seen  in  the  tracing  (see  Fig.  48).  The  body  of  the  jaw  drops 
downward  and  backward  and  the  ramus  slides  forward.  No  dental 
splint  is  practicable,  because  there  are  no  teeth  on  one  side  of  the 
fracture  to  which  the  splint  could  be  attached.  Etherization 
will  often  be  found  helpful,  and  at  times  necessary,  in  the  reduc- 
tion of  this  deformity.  Reduction  is  accomplished  by  pressure 
backward  upon  the  ramus  with  the  thumb  in  the  mouth  and  a 
simultaneous  lifting  forward  and  upward  of  the  body  of  the  jaw. 
Reduction  is  maintained  by  an  outside  pad  and  metal  chin-piece 
and  a  buckle   and   strap   splint.      This   buckle  and  strap  splint 


66. — Interdental  splint  used  in  fracture  of  the  jaw  when  no  teeth  exist  in  upper  alveolar 
arch  (after  Moriarty). 


(see  Fig.  67)  is  of  great  advantage  because  it  is  easily  adjusted, 
and  the  amount  of  pressure  can  be  graduated.  It  is  of  impor- 
tance to  note  here  that  even  after  this  fracture  has  been  reduced 
and  is  at  the  outset  apparently  held  reduced  by  the  bandage,  yet 
it  will  usually  slump  away  a  little  and  at  the  end  of  the  first 
twenty-four  hours  after  setting  the  fracture  the  fragments  will  be 
found  to  be  partially  unreduced.  Upon  a  second  application  of 
pressure  by  tightening  the  bandage  the  fragments  will  come  into 
apposition  with  comparative  ease.  By  careful  and  repeated  ad- 
justments of  the  bandage  and  padding,  after  a  week  and  a  half 
even  in  the  most  obstinate  cases,  the  jaw  will  be  found  to  be  in 
good  position,  with  the  teeth  articulating. 


7o 


FRACTURES  OF  THE  HONES  OF  THE  FACE 


Fracture  of  the  Body  of  the  Ramus  upon  the  Same  or  Oppo= 
site  Sides  of  the  Inferior  Maxilla. — The  fracture  is  difficult  to 
hold  fixed.  In  this  case  the  dental  aluminium  or  rubber  splint 
will  be  needed,  together  with  the  outside  pressure  made  by  the 
metal  chin-piece. 

Whichever  method  of  treatment  is  adopted,  the  fracture  at 
first  should  be  inspected  daily  in  order  to  insure  accurate  adjust- 
ment of  apparatus.  The  mouth  and  teeth  should  be  kept 
scrupulously  clean.  When  practicable,  the  teeth  should  be 
scaled  by  a  dentist  before  permanent  apparatus  is  applied. 
Brush  and   swab  with   some   mild   antiseptic  wash,  such   as  Lis- 


//,- 


Fig.  67. — Molded  leather  chin-piece  with  buckles  and  straps  for  graduated  pressure  upon 
a  fracture  of  the  inferior  maxilla  (after  Moriarty). 


terin,  one  part  in  four  of  water,  should  be  used  after  taking  nour- 
ishment and  before  bedtime  and  upon  rising  in  the  morning. 
The  liquid  nourishment  of  the  patient  should  be  given  through 
a  glass  tube  at  first.  If  it  is  unwise  to  open  the  mouth,  a 
rubber  catheter  may  be  used  behind  the  molar  teeth.  The  rubber 
catheter  with  a  siphon  attached  is  a  very  satisfactory  method  of 
feeding.  The  general  health  should  receive  careful  attention.  A 
patient  with  this  fracture  is  apt  to  become  despondent  and  anxious 
about  himself,  particularly  if  suppuration  exists.  The  repeated 
swallowing  of  foul  secretions  impairs  the  appetite,  causes  indiges- 
tionand  generally  poor  health.  Tin-  loss  of  variety  in  diet  favors 
this  condition.    <  )ut-of-door  exercise,  plenty  of  sleep,  a  mild  tonic, 


TREATMENT  /I 

such  as  ferrated  elixir  calisayae  and  sulphate  of  strychnin,  and  a 
little  wine,  will  all  assist  in  restoring  and  maintaining  good 
health. 

Abscesses  which  appear  should  be  treated  by  incision,  evacua- 
tion of  their  contents,  drainage,  and  antiseptic  dressings.  Bits 
of   necrosed    bone    should    be    removed.      Union  in   fracture    of 


Fig.  68. — If  no  lower  teeth  exist,  the  artificial  teeth  may  be  utilized,  as  seen  above,  as  a 
snlint.  Boxes  seen  on  sides  of  plate,  to  which  arms  and  chin-pieces  can  be  attached  (after 
Moriarty). 


the   jaw  occurs    ordinarily  in  from   three    to  five  weeks.     The 
apparatus  is  to  be  worn  until  the  union  of  the  fracture  is  firm. 
Fracture  of  the  coronoid   and   articular   processes   is   to  be 

treated  by  simple  immobilization  of  the  jaw. 

These  various  methods  of  immobilization  mentioned  may  fail 
in  some  unusual  fractures  ;  if  so,  suturing  of  the  fracture  through 
the  bone  with  silver  wire  or  other  material  should  be  undertaken. 


CHAPTER  III 
FRACTURES  OF  THE  VERTEBRAE 

Anatomy. — The  forked  spine  of  the  axis  may  be  felt  beneath 
the  occiput  upon  deep  pressure.  The  spines  of  the  third,  fourth, 
and  fifth  cervical  vertebrae  recede  from  the  surface,  and  can  not 
be  felt  distinctly.  The  spines  of  the  sixth  and  seventh  vertebra; 
project  distinctly,  and  can  be  palpated.  At  the  bottom  of  the 
furrow  in  the  middle  line  of  the  back  are  felt  the  spines  of  the 
dorsal  and  lumbar  vertebrae.  The  spinous  processes  from  the 
seventh  cervical  to  the  third  sacral  are  subcutaneous.  The 
spinal  cord  extends  from  the  lower  edge  of  the  foramen  magnum 
to  the  lower  border  of  the  body  of  the  first  lumbar  vertebra. 
The  phrenic  nerve  leaves  the  spinal  canal  between  the  third  and 
fourth  cervical  vertebras.  By  palpation  through  the  mouth  (see 
Figs.  69,  70)  the  bodies  of  the  vertebrae  may  be  felt  down  to 
about  the  upper  border  of  the  body  of  the  fifth  vertebra.  The 
cervical  enlargement  of  the  spinal  cord  is  more  marked  than 
the  lumbar  swelling.  It  commences  at  the  third  cervical  ver- 
tebra and  ends  at  the  second  dorsal  vertebra.  The  lumbar 
enlargement  commences  at  the  level  of  the  ninth  dorsal  vertebra 
and  reaches  to  the  twelfth  dorsal  vertebra.  The  spinal  cord  is 
well  protected  from  injury  (see  Fig.  71). 

The  vertebrae  commonly  fractured  are  the  fourth,  fifth,  and 
sixth  cervical,  the  twelfth  dorsal,  and  the  first  lumbar.  The 
injury  to  the  vertebrae  is  caused  in  one  of  three  ways  :  by  a 
direct  blow  upon  the  arches  of  the  vertebrae,  fracturing  the 
arches  ;  by  a  fall  upon  either  the  head  or  the  buttocks,  crush- 
ing the  bodies  of  the  vertebrae  ;  or  by  forced  flexion  or  exten- 
sion of  the  spine,  causing  a  dislocation  with  or  without  fracture 
of  the  bodies  and  articular  processes.  More  than  one-half  of 
the  fractures  of  the  cervical  vertebrae  arc  fractures  of  the  spinous 
processes.      More  than  two-thirds  of  the  cases  of  fracture  of  the 

72 


ANATOMY 


73 


dorsolumbar  vertebrae  are  fractures  of  the  bodies  of  those  ver- 
tebrae. A  dislocation  without  fracture  may  occur  in  the  cervical 
region  ;  it  is  rare  in  other  regions  of  the  spine. 


Pig-  69.— Palpating  the  bodies  of  the  first  and  second  cervical  vertebrae  through  the  mouth. 


Fig.  70.— Palpating  the  bodies  of  the  cervical  vertebrae  through  the  mouth.     Finger  reaches 
about  to  the  fourth  cervical  vertebra. 

It  is  important  in  localizing  spinal-cord  lesions  to  know  the 
point  at  which  each  nerve  arises  from  the  spinal  cord,  because 
the  point  of  origin  does  not  correspond  with  that  at  which  the 


74 


FRACTURES    OF    THE    VERTEBR.K 


nerve  emerges  from  the  spinal  canal  (see  Fig.  72).  The  point 
of  origin  is  higher  than  the  point  of  exit.  Many  of  the  nerves 
pass  obliquely  from  the  cord,  King  still  within  the  vertebral 
canal  after  leaving  the  cord  (see  Fig.  73).  These  nerves  within 
the  canal  are  liable  to  pressure  from  the  vertebral  fracture.  For 
example,  a  fracture  of  the  eleventh  dorsal  vertebra  would  injure 
not  only  the  cord  at  this  level,  but  in  addition  might  injure  the 


Fig.  71. — The  cord  and  its  membranes  in  relation  to  a  vertebra  (diagram)  :  a,  Extradural 
space;  b,  dura,  c,  subarachnoid  space ;  rf,  spinal  cord. 


Fig.  72.  — Frontal  section  of  fourth, 
fifth,  and  sixth  cervical  vertebrae  and 
Cord,  showing  the  origins  of  spinal 
nerve-roots  (after  Riidinger). 


Fig.  73- — Frontal  section  of  third,  fourth,  and  fifth 
dorsal  vertebrae,  showing  oblique  course  ol  nerve  bun 
dies  running  downward  (after  Riidinger). 


last  dorsal  and  upper  lumbar  nerves.  The  lower  the  spinal 
nerves  arise,  the  longer  is  their  intraspinal  course.  The  points 
of  origin  of  the  spinal  nerves  from  the  cord  with  reference  to 
the  spines  of  the  vertebrae  are  as  follows  (see  Fig.  74)  :  The 
eighth  cervical  nerves  arise  from  the  cord  between  the  occiput 
and  the  sixth  cervical  spine.  The  upper  six  thoracic  nerves 
arise   from   the   cord   between    the   sixth    cervical   spine  and  the 


EXAMINATION 


/  :> 


fourth  dorsal  spine.  The  lower  six  thoracic  nerves  arise  from 
the  cord  between  the  fourth  and  tenth  dorsal  spines.  The  five 
lumbar  nerves  arise  from  the  cord  opposite  to  the  eleventh  and 
twelfth  dorsal  spines.  The  five  sacral  nerves  arise  from  the 
cord  opposite  to  the  first  lumbar  spine.  No  hard-and-fast  rule 
at  present  is  applicable  to  the  enumeration  of  the  lesions  follow- 
ing the  dislocations  of  definite  vertebne.  From  the  combined 
experience  of  such  clinicians  as  Gowers,  Kocher,  Putnam,  Den- 
nis, Walton,  Bullard,  Thomas,  and  others  the  following  table  is 
constructed,  and  is  valuable  for  practical  use  : 


TABLE  STATING   LESIONS  FOLLOWING    INJURY  TO    DEFINITE 

VERTEBR.E. 


Spinal 
Segments. 

Cervical  : 


Musci.es  Involved. 


First,    second, 
third,   .    .    .  [Death]. 


Fourth, 
Fifth,  . 
Sixth, 
Seventh, 
Eighth, 

Dorsal,     . 

Lumbar : 
Second, 

Third, 

Fourth, 

Fifth, 


Vertebrae 
Dislocated. 


Skull  on  atlas,  atlas  on 
axis. 


Reflexes  In- 
volved. 


Diaphragm.  Axis  on  third  cerv 

Biceps,  supinators,  deltoid.  Third  on  fourth. 

Pronators,  triceps.  Fourth  on  fifth. 

Extensors,  flexors  of  wrist.  Fifth  on  sixth. 

Intrinsic  muscles  of  hand.  Sixth  on  seventh. 

Abdominal  muscles. 


ical.  \ 


Pupil  is  small 
and  reaction 
sluggish. 

Epigastric,  ab- 
dominal. 


Cremaster.  Eleventh     on    twelfth      Cremasteric. 

dorsal. 
Adductors. 
Outward  rotators. 
Extensors  of  thigh,  flexors  Twelfth  on  first  lumbar.   Gluteal. 

of  knee. 


Sacral  : 

First,  .... 

Second,  third, 

fourth,  fifth, 


Extensors  of  foot. 
Perineal  muscles. 


First  on  second  lumbar.    Plantar. 

Ankle-clonus. 


Examination  of  an  Injury  to  the  Spine. — Four  questions 
are  to  be  answered  :  What  was  the  nature  of  the  accident  ?  What 
does  palpation  of  the  spine  reveal  as  to  the  nature  of  the  lesion  ? 
What  is  the  level  of  the  lesion  ?  Is  the  lesion  partial  or  com- 
plete ? 


76 


FRACTURES    OF    THE    VERTEBRAE 


General  Symptoms  Common  to  Fractures  of  the  Ver- 
tebrae.— Signs  of  shock  will  be  present.  At  the  seat  of  the  bony 
lesion  will  be  found  pain,  tenderness,  abnormal  mobility,  crepitus, 
and  deformity.  The  deformity  will  ordinarily  be  a  backward 
bending,  or  kyphosis,  of  the  spinal  column  at  the  seat  of  frac- 
ture, unless  there  exists  a  unilateral  dislocation,  when  the  deform- 
ity will  be  irregular  in  appearance.      The  chief  symptoms  depend 


, oLoujer  6 

dorsal  nerves- 


Fig.  74.— Diagram  of  spinal  origin  of  nerves,  according  to  the  level  of  the  spinous  processes. 


upon  the  injury  done  to  the  spinal  cord.  In  general  it  may  be 
stated  that  motor  and  sensory  paralysis,  either  partial  or  com- 
plete, will  be  found  up  to  the  level  of  the  lesion.  The  reflexes 
are  ordinarily  increased  below  the  lesion.  Retention,  and  later 
incontinence,  of  urine  and  feces  will  exist.  Cystitis  of  the 
urinary  bladder  will  develop  at  an  early  date.  Bed-sores  and 
great  sloughing  areas  of  skin  upon  dependent  parts  will  be  dis- 
covered early.      Priapism  occurs. 


SYMPTOMS 


77 


Symptoms  of  Fracture  of  the  Different  Regions  of  the 
Spine,  the  Cord  Being  Involved. — Injuries  to  the  Last  Dorsal 
and  Lumbar  Vertebrae  (see  Figs.  75,  76,  77).— The  spinal  cord 


Fig.  75 —Fracture  of  the  twelfth  dorsal  vertebra^  Anesthesia  to  the^height  oi  the  anterior 


superior  spinous  processes  in  front.     Second  lumbar  nerve  involved. 


Fig.  76.  FiS-  77- 

Fi°-s  76  77  —Fracture  of  the  twelfth  dorsal  vertebra  without  involvement  of  the  first  lum- 
bar ne'rve-roots,  the  ilioinguinal,  iliohypogastric,  and  external  cutaneous  nerves  not  being 
involved. 

ends  opposite  the  lower  border  of  the  first  lumbar  vertebra.   Any 
pressure  at  this   point  or  below  will   involve  the  cauda  equina  in 


78 


FRACTURES  OF  THE  VERTEBRAE 


whole  or  in  part  (see  Figs.  78,  79).  Local  evidences  of  the 
bony  lesions  may  be  present.  The  paralysis  of  the  legs  may 
be  partial  or  complete.  The  anesthesia  of  the  lower  limbs 
is  partial  rather  than  complete  and  up  to  the  level  of  the 
bony  lesion.  Retention  or  incontinence  of  urine  and  feces 
exists.  The  paralyzed  muscles  rapidly  become  wasted.  Con- 
stant pain  and  hyperesthesia  may  be  present  both  above  and 
below  the  lesion.  The  patellar  and  plantar  reflexes  are  usually 
lost. 

The    prognosis   is    not  altogether    unfavorable    to    recovery. 


Fig.  78- 


Eig.  79- 


Figs.  78,  79. — Injury  to  the  cauda  equina,  which  has  involved  the  third  sacral  nerves.     Fr.u 
ture  of  the  first  lumbar  vertebra  or  the  second  lumbar  vertebra. 


Partial  recovery,  so  as  to  be  able  to  move  about,  is  probable. 
Later,  muscular  contractures  will  exist  in  the  lower  limbs,  which 
impede  walking.  If  at  the  end  of  six  weeks  evidences  of  begin- 
ning recover}-  do  not  appear,  or  if  recovery  once  begun  has  ceased, 
it  will  be  wise  to  operate  upon  injuries  to  the  cauda  equina. 

Injuries  to  the  Dorsal  Vertebra;  (second  to  the  eleventh)  (see 
Fig.  80). — The  simple  distribution  of  the  spinal  dorsal  nerves 
makes  the  interpretation  of  injuries  to  this  region  much  easier 
than  similar  injuries  to  the  cervical  or  lumbar  regions.  The  arms 
escape  paralysis.      The  motor  and  sensor)'  paralysis  extends  ordi- 


SYMPTOMS 


79 


narily  to  the  height  of  the  bony  lesion.  In  a  (c\v  cases  in  which 
the  nerve-trunks  within  the  canal  are  not  implicated  the  level  of 
the  paralysis  will  be  lower  than  the  lesion.  The  patellar  reflexes 
are  increased.  If  the  patient  recovers,  there  will  be  spastic 
paralysis  if  the  injury  is  above  the  lumbar  enlargement.      If  the 


Fig.  80.— Sixth  dorsal  vertebra  fractured.     Anesthesia  at  the  level  of  two  inches  above  the 
umbilicus.     The  eighth  or  ninth  dorsal  nerve  involved. 


Fig.  81. — Lesion  of  spine  between  fifth 
and  sixth  cervical  vertebrae.  Note  position 
of  arms,  due  to  paralysis  of  subscapularis. 
Biceps  brachialis  amicus,  supinator  longus 
and  deltoid  muscles  intact.  Elbow  flexed, 
shoulders  abducted  and  rotated  outward 
(after  Thorburn). 


Fig.  82.— Luxation  of  sixth  and  seventh 
cervical  vertebras  ;  typical  attitude  ;  center  for 
subscapularis  not  involved  (alter  Kocher). 


lumbar  enlargement  is  involved,  there  may  be  great  pain  in  the 
legs. 

Injuries  to  the  Cervicodorsal  Region,  Opposite  the  Cervical 
Enlargement  of  the  Spinal  Cord. — The  arms  escape  paralysis, 
perhaps,  at  first,  but  become  involved  after  several   days.      The 


So 


FRACTURES  OF  THE  VERTEBRA 


paralysis  is  often  partial.  Respiration  is  diaphragmatic  only. 
Pain  in  the  arms  is  quite  constant.  If  the  sixth  vertebra  is  dislo- 
cated upon  the  seventh,  the  intrinsic  muscles  of  the  hand  will  be 
paralyzed.  If  the  fifth  vertebra  is  dislocated  upon  the  sixth, 
there  will  appear  a  characteristic  position  of  the  upper  extremi- 
ties (see  Fig.  Si)  :  abduction  of  the  arms,  flexion  of  the  forearms, 
with  rotation  outward  of  the  whole  extremity.  If  the  injury  is 
above  the  sixth  cervical  vertebra,  there  will  be  anesthesia  of  the 
entire  limb  excepting  the  outer  side  of  the  arm  and  forearm  and 
the  radial  border  of  the  thumb.  The  attitude  after  lesions 
between   the  sixth   and   seventh   cervical   vertebras   is   shown  in 


i  y  \  mm 

4 


m 


Fig.  83. — Lesion  of  spine  between  sixth 
and  seventh  cervical  vertebrae.  Position  in 
case  of  complete  transverse  destruction  of 
the  cord  just  below  nuclei  for  subscapularis  ; 
areas  of  anesthesia  shown  (after  Thor- 
burn). 


Fig.  84. — Atlas,  axis,  and  third  cervical 
vertebra  from  the  front.  Case:  man,  thirty- 
eight  years  of  age  ;  fell  from  a  cart.  Frac- 
ture of  odontoid  process.  Slight  hemor- 
rhage into  the  medulla.  Death  after  forty- 
eight  hours  (Cabot). 


figure  82.  The  characteristic  attitude  in  lesions  between  the 
sixth  and  seventh  cervical  vertebrae  is  also  shown  in  figure  82. 

Injuries  to  the  Midcervical  Region. — A  lesion  of  the  fourth 
or  fifth  cervical  vertebra  will  involve  the  phrenic  nerve.  The 
diaphragm  will  be  paralyzed.  Death  will  occur  within  a  few 
hours. 

Injuries  to  the  First  Two  Cervical  Vertebras  (sec  Figs.  84, 
85). — If  the  displacement  is  slight,  life  may  be  spared  until 
sudden  displacement  occurs  or  a  secondary  myelitis  causes 
death.  Cases  of  recover}-  are  recorded.  Death  usually  occurs 
instantly.  Perhaps  one  person  in  fifty  thus  injured  recovers 
ers). 


PROGNOSIS    AND    TREATMENT  5  1 

Prognosis. —  The  prognosis  depends  upon  the  amount  of  in- 
jury to  the  spinal  cord.  The  prognosis  is  less  grave  than  it  was 
thought  to  be  a  few  years  ago.  There  is  a  probability  of  saving 
a  limited  number  of  cases.  In  general,  the  nearer  the  fracture 
approaches  the  medulla  oblongata  and  the  foramen  magnum,  the 
more  serious  does  the  outlook  become.  Patients  with  fracture 
in  the  dorsal  and  lumbar  regions  die  in  the  course  of  months 
from  cystitis,  pyelitis,  and  exhaustion.  Patients  with  fractures 
in  the  upper  dorsal  and  lower  cervical  regions  die  in  a  few  days 
or  weeks    from   hypostatic   pneumonia.      Patients  with    fractures 


Fig.  85. — Fracture  of  the  atlas  and  axis.  Man,  seventy-four  years  of  age;  fall;  imme- 
diately left  arm  paralyzed.  No  loss  of  consciousness,  speech  thick.  Neck  movements  nor- 
mal. Twenty-four  hours  after  the  accident,  suddenly  difficult  breathing  appeared  and  death 
followed  (Brooks). 

high   up  in   the  cervical   region   die  instantly  or  in  a  few  hours 
from  shock  and  direct  pressure  upon  the  medulla  oblongata. 

Treatment. — The  object  of  treatment  is  to  relieve  the  cord 
from  pressure  and  to  immobilize  the  fracture.  The  cord  will 
be  uninjured,  slightly  injured,  or  injured  seriously.  If  the 
cord  is  uninjured,  the  bony  parts  may  be  left  untouched  or 
they  may  be  replaced  by  manipulation  or  operation.  If  the 
cord  is  injured,  the  advisability  of  operative  interference  will 
depend  upon  whether  the  lesion  of  the  cord  is  transverse  and  com- 
plete, or  whether  it  is  partial.  If  there  are  evidences  of  a  trans- 
verse lesion,  operation  is  unavailing  and  obviously  illogical,  for 
the  cord  can  not  be  repaired.  It  is  necessary,  therefore,  to  distin- 
guish between  the  signs  of  a  transverse  lesion  and  those  of  a  par- 


FRACTURES  OF  THE  VERTEBRAE 


tial  lesion.  In  a  complete  transverse  lesion  the  history  of  the 
onset  of  the  symptoms  is  a  sudden  one,  the  symptoms  appear 
immediately  following  the  fracturing  trauma  ;  whereas,  if  a  partial 
injury  is  present,  an  interval  will  have  elapsed  before  the  symp- 
toms develop;  the  appearance  of  symptoms  is  gradual  rather 
than  sudden.  In  a  complete  transverse  lesion  the  motor  par- 
alysis is  found  to  be  complete, 
and  the  paralyzed  muscles  are 
flaccid  ;  whereas  if  the  lesion  is 
a  partial  one,  the  motor  paralysis 
is  limited,  some  muscles  of  the 
limbs  are  paralyzed,  others  are 
not,  and  there  is  often  noticed 
muscular  spasm  in  the  affected 
limbs.  In  a  complete  transverse 
lesion  sensation  is  entirely  gone  ; 
whereas  in  a  partial  lesion  some 
sensation  is  felt.  The  knee- 
jerks  are  variable  in  the  com- 
plete transverse  lesion  ;  they  are 
often  absent.  In  the  partial  lesion 
they  are  usually  present.  In  the 
transverse  lesion  the  paralysis  oi 
the  bladder  and  rectum  is  com- 
plete ;  whereas  in  the  partial 
lesion  paralysis  of  these  organs 
is  not  always  present.  Priapism, 
sweating,  and  involuntary  mus- 
cular twitchings  are   seen  more 

spine;    cord    compressed    by    bone    and       rommonlv    in    rase    of  iniurv    to 
blood.    Hemorrhage  into  the  cord  al  the       commonly    m    case    01    injur)     CO 

,1"'   lesio"    •""l    below   the    lesion        .1  crvin#»    iccnriar^H    u/irli     rnm 

(Warren  Museum).  (Drawn  by  Byrnes.)  me  spine  associated  WUIl  com- 
plete lesions  of  the  cord  than 
in  cases  with  partial  lesions  of  the  cord.  In  partial  lesions 
variations  from  the  definite  types  of  symptoms  are  seen.  The 
symptoms  are  more  or  less  irregular.  In  total  lesions  of 
the  cord  operation  can  do  no  good.  The  cases  of  pressure 
from  fragments  of  bone — that  is,  those  occurring  for  the  most 
part  in  the  cervical  region,  in  which  the  laminae  of  tin   vertebrae 


56.  —  Fracture     of     the    cervical 


i  k i:\t.\ik\t 


83 


are  fractured — demand  operation.  All  other  cases  of  bony 
pressure  are  those  due  to  dislocation  of  vertebrae  which  are 
remediable  either  by  operation  or  manipulation.  In  these  cases 
the  prognosis  depends  upon  the  damage  done  the  cord. 

It  is  the  result  of  experience  that  in  cases  of  injury  to  the 
spine  severe  enough  to  do  damage  to  the  cord  usually  irreparable 
injury  has  been  done  by  either  a  distinct  crush  of  the  cord  or  hemor- 
rhage into  the  cord.  Hemorrhage  into  the  cord  takes  place  often 
extensively  and  some  distance  from  the  seat  of  the  chief  lesion, 
so  that  even  if  the  seat  of  the  crush  of  the  cord  were  reached 
by  operation,  damaging  lesions  would  still  remain  unrelieved. 


Fig.  87. — Case:  Man,  fracture  of  spine;  transverse  section  of  spinal  cord  above  the  lesion. 
Hemorrhage  into  posterior  horn  (Taylor).    (Drawn  by  Byrnes.) 

It  is  also  the  result  of  experience  that  removal  by  operation 
of  the  laminae  and  spines  of  the  vertebrae  in  the  suspected 
region  of  fracture  very  rarely — almost  never — reveals  any  reme- 
diable condition  or  affords  any  evidence  of  the  exact  seat  of  the 
lesions  or  their  extent.  The  reason  for  these  facts  is  that  the 
dura  at  the  seat  of  a  crush  of  the  cord,  whether  partial  or  com- 
plete, remains  intact  and  untorn,  and  that  extradural  hemorrhage 
is  unusual.  The  surgeon,  therefore,  after  removal  of  the  lamina' 
is  as  much  in  doubt  as  he  was  before.  Operation,  therefore, 
in  complete  lesions  holds  out  no  hope  of  benefit.  It  is 
said  that  the  chances  of  the  symptoms  being  due  to  pressure 


84 


FRACTURES    OF    THE    VERTEBRAE 


by  extradural  blood-clot  or  bone  justify  operative  interference 
in  these  apparently  hopeless  cases.  This  is  true  in  those  cases  in 
which  the  lesion  of  the  cord  is  partial,  but  never  when  the  lesion 
is  completely  transverse. 

Operative  interference,  then,  may  be  summarized  somewhat 
as  follows  : 

In  all  partial  lesions  operation  is  demanded  ;  in  fractures  of 
the  laminae  and  spines  operation  is  demanded  ;  in  all  lesions  of 
the  cauda  equina  operation  is  demanded  ;  in  all  complete  lesions 
operation  is  contraindicated. 

It  is  an  interesting  fact  clinically  and  pathologically  that  in  cords 
compressed  at  a  definite  level  with  destruction  of  the  cord,  at  the 


Fig.  88  — Case  :  Man,  fracture  of  spine  ;  transverse  section  of  spinal  cord  below  the  lesion  (Taylor).  (  Drawn 

by  Brynes.  i 

seat  of  compression  there  is  often  found  a  hematomyelia  (hemor- 
rhage into  the  substance  of  the  cord)  several  vertebra.-  above  and 
below  the  fracture,  thus  showing  how  extensive  is  the  acting  force. 

A  study  of  the  drawings  made  from  actual  sections  of  the 
spinal  cords  of  cases  of  fracture  of  the  spine  will  indicate  the 
different  lesions  already  mentioned. 

Figure  86  is  from  a  fracture  of  the  cervical  vertebra',  showing 
destruction  of  the  cord  at  the  seat  of  the  lesion,  with  localized 
pressure  from  bone  and  blood.  Low  down  is  seen  an  extensive 
extradural  hemorrhage  and  a  hematomyelia  some  distance  from 
tie-  original  trauma. 


TREATMENT 


85 


Figure  Sy  is  from  a  dislocation  and  fracture  of  the  fifth  upon 
the  sixth  cervical  vertebra.  There  was  complete  paralysis  below 
the   lesion.      Trephining  was   done.      The  patient  lived  without 


Fig.  Sg. — Case:  Man,  fracture  of  spine;  transverse  section  of  spinal  cord  at  the  seat  of 
lesion  (Taylor).     (Drawn  by  Byrnes.) 


Fig.  90. — Case:    Fracture  of  the  spine;  transverse  section  of  spinal  cord  several  segments 
from  the  lesion  ;  hemorrhage  into  the  white  matter  (Taylor).     (Drawn  by  Byrnes.) 

improvement  seventeen  days.  This  section  of  the  cord  is 
taken  a  little  above  the  lesion  and  shows  clearly  a  hemato- 
myelia  of  the  right  posterior  cornu. 


86 


FRACTURES    OF    THE    VERTEBR.E 


Figure  88  is  taken  from  a  section  of  the  cord  of  the  preced- 
ing case  a  little  below  the  lesion,  showing  complete  destruction 
of  the  gray  matter  of  the  cord  ;  the  dura  remained  intact. 

Figure  89  is  also  taken  from  a  section  of  the  cord  of  the  pre- 
ceding case,  but  at  the  seat  of  the  lesion,  showing  a  destruction 
of  the  gray  and  white  matter  of  the  cord  anteriorly  next  to  the 
bodies  of  the  vertebrae.  The  dura  remained  intact,  there  being 
to  the  operating  surgeon  no  evidence  posteriorly  of  any  disturb- 
ance having  occurred  anteriorly. 


Fig.  91.— Fracture  of  lumbar  vertebrae  (Warren  Fig.  92.— Partial  fracture  of  twelfth 

Museum).  dorsal    and    fracture    of   first    lumbal 

vertebrae.  Fall  of  twenty  feet  on  nates. 
Paraplegia  and  sphincter  paralysis. 
Death  nine  months  after  accident.  Died 
of  phthisis.  Type  of  compression  frac- 
ture (Warren  Museum,  specimen  941). 

Figure  90  is  a  section  of  the  spinal  cord  of  a  woman  who  fell 
from  a  trapeze  to  the  floor,  and  fractured  and  dislocated  the 
sixth  cervical  vertebra.  <  )peration  was  done.  She  lived  three 
days.  A  little  distance  (two  segments)  from  the  seat  of  the  lesion, 
where  the  cord  was  crushed  anteriorly,  was  found  a  hema- 
tomyelia  of  the  white  matter  posteriorly.  The  dura  was 
intact. 

These  specimens,  which  illustrate  the  common  lesions  of  the 
spinal  cord  following  fractures  and  dislocations  of  the  vertebrae, 


TREATMENT 


87 


demonstrate  the   utter  futility  of  operative  interference  in  cases 

of  crush  of  the  cord  with  signs  of  a  complete  transverse  lesion. 

The   Immediate   Rectification  of  the   Deformity  and    Immo= 

bilization    by  the   Plaster=of=Paris  Jacket. — With   our  present 

knowledge  of  the  pathology  of  these  fractures,  and  excepting 
cases  of  fracture  of  the  vertebral  arch  alone  and  pressure  upon 
the  can  da  equina  and  partial  lesions  of  the  cord,  there  can  be  no 
doubt  that  the  best  treatment  for  fracture  of  the  vertebrae  is  by 


On 


Fig-  93- — Old  fracture  of  twelfth  dorsal  ver- 
tebra, from  fall  of  thirteen  feet  ;  canal  nar- 
rowed. Total  paralysis  of  motion  and  sensa- 
tion below  injury.  Died  two  years  after  acci- 
dent (Warren  Museum,  specimen  4629). 


Fig.  94.  —  Fracture  of  twelfth  dorsal 
vertebra.  Laceration  of  intervertebral 
disc  above  twelfth  vertebra  ;  crushed 
by  fall  of  ceiling.  Paralyzed  from  be- 
low navel.  Paralysis  of  bladder  and 
rectum.  Died  nine  and  a  half  weeks 
after  the  accident. 


means  of  expectant  methods.  The  methods  are  as  follows  : 
Immobilization  of  the  part  by  a  plaster-of- Paris  jacket  applied  to 
the  trunk,  if  there  is  no  deformity.  If  there  is  deformity,  cor- 
rection of  it  and  immobilization  of  the  spine  in  the  corrected 
position.  The  correction  of  the  deformity  must  be  immediate  to 
avoid  irremediable  softening  of  the  cord  from  pressure  ;  and  this 
may  occur  even  within  forty-eight  hours. 

Method  of  Applying  the  Plaster-of-Paris  Jacket. — This  differs 
in   no  respect  from  the   usual  methods  of  application,  with   the 


S8 


FRACTURES    OF    THE    VEKTEBR.E 


exception  that  the  patient  should  be  protected  from  any  unusual 
or  sudden  jar  or  movement.  The  trunk  having  been  properly 
protected  by  a  tightly  fitting  shirt,  the  patient  is  carefully  placed 
prone  in  a  hammock.  The  patient  may  be  placed  upon  two  kitchen 
tables,  which  are  gradually  pulled  apart,  allowing  the  trunk  to  be 
unsupported  between  the  tables  until  the  desired  extension  is  ob- 
tained.     If  the  tables  are  used,  great  care  must  be  exercised  that 

proper  assistants  secure  the 
shoulders  and  hips  of  the 
patient  during  the  proced- 
ure. Gentle,  firm  pressure 
is  made  upon  the  projecting 
^yP^h  vertebral  spines  until  re- 
duction is  complete.  The 
jacket,  reinforced  poste- 
riorly by  extra  layers  of 
bandage,  is  then  applied. 
Death  may  occur  instantly 
during  this  procedure,  but 


Fig.  95- — Fracture  of  seventh  dorsal  vertebra, 
with  great  displacement  of  fragments,  from  a  fall  oi 
thirty  feet.  Paraplegia,  loss  of  sensation  from 
nipple  down.  Sensation  later  recovered  down  to 
navel.  Died  two  months  after  accident  (Warren 
Museum,  specimen  6229). 


Fig.  96. — Dislocation  forward  ol 
sixth  cervical  vertebra,  from  fall  on 
head.  Total  paralysis  below  nipples. 
Temperature  rose  to  110°  F.  Died  eigh- 
teen hours  after  accident.  Illustrates 
displacement  of  spinous  processes 
(Warren  Museum,  specimen  4904). 


if  gentle  measures  are  used,  the  likelihood  of  such  a  catastrophe 
will  be  modified.  An  anesthetic  given  to  primary  anesthesia  is 
often  of  service.  A  sufficient  number  of  assistants  should  be  at 
hand — there  should  be  at  least  four. 

It  is,  of  course,  impossible  to  say  what  cases  will  be  saved  by  this 

means,  but  it  has  been  proved  to  be  a  life-saving  measure  in  a  few 

.    The  patient  will  be  more  comfortable  and  more  easily  man- 


TREATMENT 


89 


aged  after  such  a  procedure.  The  hopelessness  of  the  results  of 
fractured  spine  justifies  the  surgeon  in  undertaking  almost  any  risk. 
Cystitis. — Life  may  be  prolonged,  if  not  saved,  by  the  proper 
treatment  of  this  distressing  affection,  which  is  always  associated 
with  fracture  of  the  spine.  In  a  number  of  these  cases  death  is 
due  to  a  pyelitis  and  nephritis  following  a  cystitis.  These  com- 
plications may  be  avoided  for  a  definite  time  if  the  bladder  is 
thoroughly  drained  by  urethral  catheter  or  by  perineal  drainage. 
The  bladder  may  be  kept  aseptic  by  douching  regularly  with  a 


Fij;.  97 — Fracture  and  subluxation  ;  cervical  vertebra:  united  (J.Mason   Warren   collec- 
tion, Warren  Museum)  (Walton). 


solution  of  boric  acid  or  permanganate  of  potash  and  by  the 
internal  use  of  urotropin.  Great  care  should  be  exercised  in  the 
avoidance  of  bed-sores  ;  it  is  easier  to  prevent  than  to  cure  them. 
Summary  of  Treatment. — Fracture  of  the  arches  of  the 
vertebras,  whether  open  or  closed,  should  be  subjected  to 
operation.  Fracture  and  compression  of  the  cauda  equina 
after  six  weeks  of  waiting  for  spontaneous  recovery  should 
be    treated    by    operation.      In    all    partial    lesions    of   the    cord 


90  FRACTURES    OF    THE    VERTEBRAE 

operation  is  demanded.      All  other  fractures  showing  a  complete 
transverse  lesion  of  the  cord  should  be  treated  expectantly. 

GUNSHOT  FRACTURES  OF  THE  VERTEBRAE 

These  open  fractures  arrange  themselves  into  three  groups  for 
practical  purposes. 

First  group.  Those  cases  in  which  the  viscera  of  the  thorax 
or  abdomen  are  simultaneously  injured. 

Second  group.  Those  cases  in  which  the  bullet  has  entered 
the  spinal  canal  and  has  injured  the  spinal  cord. 

Third  group.  Those  cases  in  which  the  spines  and  laminae 
or  the  arches  of  the  vertebrae  are  injured. 

Treatment. — In  all  cases  the  external  wound  should  be  care- 
fully cleansed  and  protected  by  an  antiseptic  dressing. 

The  degree  of  shock  should  be  observed.  Any  signs  of  a 
lesion  of  the  cord  should  be  recorded.  Evidence  of  damage  to 
the  viscera  within  the  chest  or  abdomen  should  be  sought  for. 

In  the  absence  of  great  shock  it  is  wise  for  the  surgeon,  under 
antiseptic  and  aseptic  conditions,  to  lay  open  the  wound,  to 
thoroughly  disinfect  it  and  to  attempt  to  ascertain  the  condition  of 
the  cord  and  vertebrae.  If  the  symptoms  point  immediately  to  a 
transverse  lesion  of  the  cord  extensive  operation  is  contra- 
indicated. 

The  character  of  the  damage  done  by  the  bullet  to  the  verte- 
brae and  spinal  cord  cannot  be  wholly  determined  except  by 
operation.  In  operating  there  is  always  the  possibility  of  dimin- 
ishing the  chances  of  infection  through  the  bullet  wound  and  of 
relieving  pressure  upon  the  spinal  cord  from  blood  clot  and 
fragments  of  bone. 

A  crushed  cord  is  not  incompatible  with  life.  Such  a  patient 
may  live  for  several  months  or  even  for  several  years.  Opera- 
tion may  prevent  death  from  sepsis,  even  il  a  crush  of  the  cord 
exists. 


CHAPTER    IV 
FRACTURES  OF  THE  RIBS 

Anatomy. — Palpation  of  most  of  the  ribs  is  comparatively 
easy.  The  upper  seven  ribs  on  each  side  articulate  with  the 
sternum.  The  eighth,  ninth,  and  tenth  ribs  are  connected  by  the 
costal  cartilages  anteriorly,  but  the  eleventh  and  twelfth  ribs 
have  no  anterior  attachment.  These  lowest  ribs  are,  therefore, 
less  liable  to  fracture.  The  first  two  ribs  are  somewhat  protected 
by  the  clavicle  from  direct  violence,  although  great  depression 
of  the  shoulder  may  bring  the  clavicle  to  bear  directly  upon  the 
first  ribs,  and  this  may  be  a  cause  of  fracture.  The  ribs  are  so 
elastic  in  childhood  that  fracture  then  is  extremely  rare.  Direct 
violence  is  the  common  cause  of  fracture. 

Symptoms. — In  partial  fractures  there  may  be  no  symptoms. 
Upon  forcible  expiration  (as  in  sneezing,  coughing,  laughing, 
crying,  or  in  breathing  hard)  pain  may  be  felt  at  the  seat  of 
fracture.  So  definite  is  the  pain  that  the  patient  may  be  able  to 
place  his  finger  accurately  upon  the  seat  of  fracture. 

Crepitus  is  often  felt  by  the  patient  when  moving  or  making 
an  expulsive  effort.  Crepitus  is  elicited  for  the  examiner  by 
firmly  placing  the  palm  of  the  hand  flat  upon  the  chest  at  the 
supposed  seat  of  fracture  when  the  patient  coughs.  If  crepitus 
is  present  at  the  time  of  coughing,  a  slight  crunch  or  click  will 
be  felt  and  sometimes  heard.  The  stethoscope  placed  near  the 
supposed  fracture  will  often  assist  in  detecting  the  crepitus.  The 
ribs  should  be  palpated  systematically,  and  the  chest  slightly 
compressed  between  the  two  open  hands  anteroposteriorly  and 
laterally  to  detect  crepitus.  The  natural  inclination  of  the 
ribs  should  be  borne  in  mind  during  palpation.  Respiration 
will  be  short  and  catchy,  and  accompanied  by  a  characteristic 
grunt. 

The  attitude  and  movements  of  the  patient  are  very  deliberate, 
guarded,  stiff,  and  in  severe  cases  suggest  the  movements  of  a 

91 


92 


FKACTLRES    OF    THE    RIBS 


child    with   acute    caries   of  the  dorsal   spine.      There  may  be  a 
slight  cough. 

Complications  of  Fracture  of  a  Rib. — Injury  to  the  pleura 
and  lung  not  uncommonly  occurs.  Its  existence  is  manifested 
by  cough,  blood\r  expectoration,  and  emphysema.  Emphysema 
may  extend  over  the  whole  chest  and  up  over  the  neck  and  face 
(see  Fig.  98),  and  even  over  most  of  the  body.  Emphysema 
unassociated  with  a  wound  of  the  superficial  soft  parts  is  of  little 
importance.  Pneumothorax  may  be  present.  Injury  to  the 
heart  and  pericardium  and  hemorrhage  from  an  intercostal  artery 
are  unusual.      A   dry  pleurisy,  disappearing   rapidly,  localized  at 


Fig.  98. — Case:  Emphysema  following  fracture  of  the  ribs  on  the  right  side.     Note  the  puffi 
ness  of  the  face — the  eyes  almost  closed  (Warren). 


the  seat  of  fracture,  is  quite  commonly  detected  by  the  steth- 
oscope. The  relations  of  a  rib  to  the  pleura  and  intercostal 
vessels  are  important  in  this  connection  (see  Fig.  99). 

Treatment. — The  complications  must  be  attended  to  accord- 
ing to  medical  principles.  A  cough  mixture,  if  necessary,  con- 
taining morphin  is  a  great  help  during  the  first  week.  It  is  diffi- 
cult to  reduce  a  fracture  of  a  rib  and  to  hold  it  reduced.  The 
deformity  and  loss  of  function  consequent  upon  the  union  of  a 
fractured  rib  in  malposition  is  fortunately  not  very  great  (see  Fig. 


TREATMENT 


93 


100).  However,  the  relief  of  the  patient  upon  the  partial  im- 
mobilization of  the  fracture  is  great.  By  pressure  of  the  hand 
the  ribs  may  be  steadied  and  the  fragments  brought  into  excel- 
lent apposition,  and  by  a  pad  held  in  place  by  a  swathe  of  adhe- 
sive plaster  this  apposition  can  be  maintained.  The  application 
of  an  adhesive-plaster  swathe  is  attended  with  much  comfort,  and 
is  easily  accomplished.  The  swathe  should  be  broad  enough  to 
cover  the  chest  six  inches  on  either  side  of  the  fracture  of  the  rib, 


Lung. 


Rib. 


■  Artery  and  nerve. 
Pleura. 


.Rib. 

Artery. 


—  Rib. 


Fig.  99. — Horizontal  section  of  chest-wall.  The  relation  of  rib  and  intercostal  vessels  and 
nerve  to  pleura  and  lung  is  shown.  Fracture  of  rib  may  cause  serious  injury  (frozen  section, 
Professor  T.  Dwight). 


Fig.  ioo. — Fractured  rib,  united  with  displacement  (Warren  Museum). 


and  long  enough  to  extend  three-fourths  of  the  way  around  the 
body.  It  is  applied  as  follows  :  One  end  is  fixed  to  the  trunk  of 
the  patient  at  the  spine,  the  patient  standing  erect  with  the  hands 
upon  the  top  of  the  head  (see  Fig.  ioi).  The  surgeon,  taking  the 
loose  end  of  the  swathe  and  holding  it  taut,  walks  around  the 
patient,  applying  the  swathe  to  the  patient's  chest  while  the  patient 
standing  turns  as  if  on  a  pivot  toward  the  surgeon  if  possible 
(see  Fig.  102).  It  is  important  to  avoid  covering  the  constantly 
moving  abdomen  bv  the  swathe.      A  swathe  made  of  several  long 


Fig.  101. — Fracture  of  the  ribs.  Starting  the  application  of  the  adhesive-plaster  swathe 
to  encircle  the  trunk.  Fixation  of  initial  end  of  the  swathe  at  the  spine.  Notice  that  the 
swathe  is  held  taut  as  it  is  applied. 


Fracture  of  the  ribs.     Finishing  tin    application  ol  the  adhesive-plaster  swathe  to 

the  trunk. 

94 


TREATMENT  95 

strips  of  adhesive  plaster,  each  strip  being  four  inches  wide,  imbri- 
cated in  the  application,  will  often  prove  more  comfortable  than  a 
single  swathe.  The  comfort  attending  the  wearing  of  such  a 
swathe  speaks  much  for  its  efficacy. 

Operative  Treatment. —  If  the  fracture  is  comminuted  or  if 
there  is  great  displacement  that  is  irreducible  by  pressure,  an 
incision  and  elevation  of  the  parts  and  immobilization  by  sutu re- 
are  to  be  considered. 

After=treatment. — The  upright  position  will  give  the  most 
comfort.  The  swathe  should  be  changed  at  least  once  each 
week.  It  will  require  about  three  weeks  for  the  union  to  become 
firm.  A  cotton  swathe  may  be  worn  during  the  third  and  fourth 
weeks  in  place  of  the  adhesive-plaster  swathe.  At  the  end  cf 
four  weeks  all  swathes  may  be  removed.  Massage  to  the  seat 
of  fracture  will,  after  the  first  week,  hasten  healing  and  a  resto- 
ration of  the  parts  to  the  normal  position.  If  there  have  been 
any  pleural  or  lung  complications,  great  precaution  should  be 
exercised  in  the  after-care.  The  avoidance  of  exposure  to  cold 
and  of  great  bodily  exertion  for  a  period  of  two  months  or  more 
following  recovery  from  the  complication  is  necessary. 

Other  injuries,  such  as  strains  of  the  shoulder  and  back,  are 
likely  to  appear  some  days  after  the  acute  symptoms  of  a  fracture 
of  the  rib  have  subsided.  It  is  well  to  examine  the  patient  with 
a  fractured  rib  for  associated  injuries.  These  associated  sprains 
often  cause  considerable  anxiety  to  the  patient  for  fear  that  more 
serious  trouble  than  a  broken  rib  exists.  In  patients  over  fifty 
years  old  "  neuralgic  pain  "  at  the  seat  of  fracture  will  sometimes 
persist  for  several  weeks  after  the  fracture  is  firmly  united.  This 
may  be  relieved  by  applications  of  moist  heat  to  the  affected  part 
and  by  counterirritation  of  a  more  vigorous  kind.  The  use  of 
tincture  of  iodin  and  blisters  is  often  a  great  help.  In  the  aged 
the  shock  of  the  injury  is  considerable.  In  feeble  persons  a 
pleurisy  or  pneumonia  may  prove  fatal. 

Treatment  directed  to  the  removal  of  the  emphysema  is  ordi- 
narily unnecessary.  The  emphysema  usually  disappears  in  a 
week  or  ten  days.  If  the  distention  of  the  subcutaneous  tissues 
is  extremely  painful  and  increases  very  rapidly  it  may  be  wise  to 
make  several  antiseptic  incisions  over  them,  allowing  the  air  to 
escape,  to  relieve  the  tension  of  the  skin. 


CHAPTER  V 
FRACTURES  OF  THE  STERNUM 

It  is  difficult  to  palpate  the  sternum  accurately.  The  epi- 
sternal  notch  is  felt  between  the  two  inner  ends  of  the  clavicles. 
The  junction  between  the  first  and  second  portions  of  the  sternum 
is  distinctly  felt  opposite  the  second  costal  cartilage  as  a  ridge. 
The  different  sites  of  fracture  are  shown   in   figure    103.      The 


Fig.  103. — Sites  of  fracture  of  the  ster- 
num (after  specimens  5149,  978,5151,5150, 
976,  977,  Warren  Museum). 


Fig.  104  — Separation  of  manubrium 
and  gladiolus  ;  displacement  of  lower  por- 
tion forward  ;  side  view. 


fracture  that  is  usually  due  to  direct  violence  is  seated  in  the 
upper  part  of  the  second  portion  of  the  sternum,  near  the  junc- 
tion of  the  first  and  second  portions.  The  upper  fragment  is 
displaced  backward  behind  the  upper  end  of  the  lower  fragment 
(see  Fig.  104).  The  displacement,  the  abnormal  mobility,  and 
possibly  crepitus  after  each   respiratory  act  or  upon    coughing, 

96 


TREATMENT    OF    KRACTUKK    OK    THE    STERNUM 


97 


the  localized  area  of  pain,  all  increased  by  pressure,  help  to  make 
the  diagnosis  certain. 

The  patient  stands  in  a  characteristic  fashion  with  body  bent 
forward.  It  is  almost  impossible  to  distinguish  a  dislocation  at 
the  junction  of  the  first  and  second  portions  of  the  sternum  from 
a  fracture  within  the  first  portion  of  the  sternum.  Careful  palpa- 
tion alone  and  consideration  for  the  age  of  the  patient  will  enable 
one  to  decide.  The  ossification  of  the  sternum  takes  place 
irregularly.  At  the  twenty-fifth  year  all  parts  are  usually  ossi- 
fied. The  lesions  sometimes  associated  with  fracture  of  the 
sternum — viz.,  fracture  of  the  ribs  and   injury  to  the    lungs   and 


Fig.  105. — Position  in,  and  method  of  reduction  of,  fracture  of  the  sternum.     Notice  positions 
of  hands  of  surgeon  and  assistant. 


heart — are  usually  so  severe  that  the  patient  does  not  recover 
from  them.  If  no  complicating  lesions  are  present,  the  outlook 
for  recovery  is  favorable. 

Treatment  of  Fracture  of  the  Sternum. — Spontaneous  reduc- 
tion has  occurred  in  several  instances  upon  coughing  or  sneezing. 
If  the  patient  is  placed  upon  his  back  with  his  head  extended  over 
the  end  of  the  table  and  the  arms  are  then  raised  above  the  head 
and  rotated  outward  slowly  and  forcibly,  the  deformity  is  some- 
times reduced.  The  body  of  the  patient,  meanwhile,  is  steadied 
by  an  assistant.  Traction  and  countertraction  are  thus  made  upon 
the  two  fragments  (see  Fig.  105).  An  adhesive-plaster  swathe 
should  be  placed  about  the  chest  high   up,  and  held  firmly  in 


9«S  FRACTURES    OF    THE    STERNUM 

position  by  straps  across  the  shoulders.  Union  takes  place  in 
from  three  to  four  weeks.  The  fracture  is  not  solid  for  from 
six  to  eight  weeks.  After  resting  on  the  back  in  bed  for  three 
weeks  the  patient  may  be  allowed  to  be  up  occasionally  with 
care  to  avoid  violent  exertion.  For  the  greatest  precaution  a 
Taylor  steel  back-brace,  with  apron  and  head-support,  should  be 
used  for  two  months  after  the  patient  is  up  and  about.  This 
brace  is  similar  to  that  used  in  high  dorsal  caries  of  the  spine. 

Operative  Treatment. — Incision  and  elevation  of  the  de- 
pressed fragment  have  been  done  successfully,  and  are  to  be 
considered  in  difficult  cases  after  the  shock  of  the  original  injury 
has  passed  away. 


CHAPTER  VI 
FRACTURES  OF  THE  PELVIS 

The  pelvic  bones  are  generally  considered  inaccessible  (see 
Fig.  1 06)  ;  but  with  a  systematic  anatomical  examination,  especi- 
ally if  assisted  by  digital  examination  by  the  rectum  and  the 
vagina,  practically  all  parts  of  the  pelvic  bones  may  be  palpated. 
Movement  of  the  hip  will  often  determine  the  integrity  of  the 
acetabulum,  which  is,  of  course,  most  difficult  to  palpate  even 
posteriorly  by  the  rectum.  Fractures  of  the  pelvis  are  occa- 
sioned by  great  violence.  Fracture  occurs  most  often  in  falls 
from  a  height,  and  is  due  to  the  sudden  pressure  upon  the  pelvis 
through  the  thighs  and  hips  (see  Fig.  107)  or  through  the  spinal 
column  upon  the  sacrum  and  sacro-iliac  synchondroses.  Antero- 
posterior pressure  and  lateral  compression,  as  in  the  car-coupling 
accident,  are  common  causes  of  fracture.  From  a  clinical  stand- 
point these  fractures  fall  into  two  groups — fractures  of  the  indi- 
vidual bones  without  injury  to  viscera,  and  fractures  at  different 
points  in  the  pelvic  ring  usually  associated  with  visceral  lesions. 

Fractures  of  the  sacrum,  the  .coccyx,  the  symphysis  pubis, 
and  the  ischium  are  extremely  rare. 

Examination. — The  examination  should  be  systematically 
made  in  order  to  cover  thoroughly  the  irregular  bones  of  the 
pelvis.  The  ilium  of  each  side  should  be  palpated  to  detect  a 
fracture  of  either  crest.  Then  the  two  ilia  should  be  crowded 
gently  but  firmly  together  in  order  to  determine  crepitus  due  to 
the  presence  of  fracture  elsewhere.  Then  the  pubis  and  ischium 
upon  the  two  sides  are  to  be  palpated  externally  as  far  as  is  prac- 
ticable. Finally,  a  careful  rectal  and  vaginal  examination  should 
be  made  of  the  pelvic  bones.  The  patient  should  be  catheter- 
ized  to  assist  in  determining  the  presence  of  an  injur}-  to  the 
urinary  tract. 

Fracture  of  the  Ilium  (see  Fig.  108). — This  fracture  is  not 
unusual.      The  crest  of  the  ilium  is  commonly  broken.      Tain, 

99 


IOO 


FRACTURES  OF  THE  PELVIS 


swelling,  crepitus,  and  abnormal  mobility  may  be  present.  There 
is  comparatively  little  displacement.  Union  occurs  in  from  three 
and  a  half  to  four  weeks.      The  patient  ordinarily  requires  but 


Fig.  106. — Normal  pelvis.     Note  relations  of  pelvic  ring.  Fig.  107. — Fracture   of  acetab- 

ulum ;  force  transmitted  through 
femur  (Warren  Museum,  specimen 
i°53)- 


—Fracture  of  crest  of  ilium  (Warren  Museum,  specimen  59.isi. 


restraint  in  bed.  The  outlook  is  for  a  good  recover}'  unless 
then-  is  a  visceral  lesion.  Slight  deformity  may  be  noticeable 
upon  full  recovery  (see  Fig.   109). 


TREATMENT    OF    FRACTURES    OF    THE    PELVIS 


IOI 


Fracture  of  the   pubic   portion   of  the   ring  of  the  pelvis  is 

the  commonest  fracture.  It  is  usually  associated  with  other 
fractures  or  separations  of  bony  surfaces  of  the  pelvis.  Injury 
to  the  urethra  is  not  uncommon  in  this  fracture  (see  Figs.  I  10, 
in). 

Treatment. — A  snugly  fitting  swathe  encircling  the  pelvis 
should  be  applied  to  assist  in  immobilizing  the  fracture.  If  the 
fracture  is  of  the  ilium  alone,  the  swathe  should  be  applied 
loosely  enough  to  avoid  displacing  the  fragment  of  the  crest  in- 
ward, thus  causing  permanent  deformity  (see  Fig.  log).  The 
patient  should,  in  all  cases,  except  simple  fractures  of  the  crest 


Fig.  109. — Case  :  Fracture  of  the  crest  of  the  right  ilium  :  A,  Deformity  due  to  inward  displace- 
ment of  fractured  bone;  E,  Posterior  lateral  view  (Porter). 

of  the  ilium,  be  placed  upon  a  properly  fitting  Bradford  frame. 
Upon  this  frame,  and  in  no  other  way,  can  the  patient  be  com- 
fortably nursed.  The  bed-pan  can  be  adjusted  with  ease  and 
without  disturbing  the  fracture.  The  bed  can  be  most  readily 
changed  and  the  patient  kept  clean  and  comfortable.  If  it  is 
probable  that  movements  of  the  hip-joints  cause  motion  at  the 
seat  of  the  fracture,  the  thighs  should  be  fixed  so  as  to  immobilize 
these  joints.  If  the  patient  is  on  a  Bradford  frame,  sufficient 
immobilization  is  easily  accomplished  by  encircling  the  thighs 
separately  or  together  and  the  frame  with  a  towel  swathe. 
Extension  of  the  limbs  by  weight  and  pulley  may  be  needed  in 


102 


FRACTURES    OF    THE    PELVIS 


addition  in  certain  cases  to  secure  immobilization  of  the  fracture. 
Wiring  or  suture  of  the  fractured  bones  may  be  entertained  and 
practised.  Wiring  is  indicated  if  comminution  or  displacement 
of  fragments  is  great. 

Visceral    Lesions. — Associated   with   fractures  of   the    pelvis 


New  bone  at 
seat  of  separation. 


•  Sacro-iliac 

synchondrosis. 


pig,  no.— Fracture  of  rami  of  pubes ;  fracture  and  separation  at  sacro-iliac  synchondrosis; 
much  displacement;  bony  union  (Warren  Museum). 


l--j<r.  ,, ,      Fractured  pelvis :  on  the  right,  fracture  across  pubes  and  ischium  ;  on  the  left,  frac- 
ture involving  acetabulum  and  sacrosciatic  notch  (Warren  Museum,  specimen  3857). 


there  may  be  lesions  of  important  viscera.  These  visceral  lesions 
render  fractures  of  the  pelvis  of  the  very  greatest  seriousness. 
The  trauma  causing  the  fracture  may  at  the  same  time  occasion 
a  rupture  of  the  kidney.     The  bladder,  urethra,  or  bowel  may 

;i1m.   be  ruptured.      The  shock    associated   with  a  fracture  of  the 


RUPTURE    OF    THE    URETHRA 


103 


pelvis  is  great.      \{  there  is  a  visceral   lesion,  the  primary  and 
secondary  shock  will  be  very  great. 

Rupture  of  the  Urethra. — This  is  sometimes  associated  with 
fracture  of  the  pelvis  (see  Fig.  112).  It  may  be  clue  to  the 
original  trauma,  as  a  fall  or  blow  on  the  perineum,  or  it  may  be 
caused  by  bony  fragments  lacerating  the  urethra,  or  by  a  simple- 
separation  of  the  symphysis  pubis.  Pain  at  the  seat  of  the  lesion, 
pain  upon   pressure  in  the  perineum,  retention  of  urine,  urethral 


Bladder. 


Sacrum.  — 


Rectum.  — | 


Symphy- 
sis pubis. 


"*  Frethra. 


Fig.  112. — Median  section  of  male  pelvis.  Notice  close  relation  of  bladder  and  urethra  to 
the  symphysis  pubis.  Fracture  of  pubic  bone  may  injure  bladder  or  urethra  (frozen  section 
by  Professor  Trios.  Dvvight). 

hemorrhage,  swelling  in  the  perineum,  usually  exist.  Under  these 
circumstances  perineal  section  is  indicated  in  order  to  drain  the 
wounded  area  and  the  bladder.  If  a  catheter  can  be  passed  to 
the  bladder  and  the  local  swelling  does  not  increase,  permanent 
or  interrupted  catheterization  is  indicated.  The  patient  should, 
however,  be  watched  carefully  for  the  signs  of  extravasation  of 
urine.  If  at  any  time  the  catheter  can  not  be  passed,  operation 
should  be  done  at  once,  as  in  the  first  instance. 


104  FRACTURES    OF    THE    PELVIS 

Rupture  of  the  Urinary  Bladder. — This  may  be  either  extra- 

or  intraperitoneal.  When  the  bladder  is  empty,  it  is  low  down 
in  the  pelvis  and  can  be  injured  only  by  a  fracture  of  the  pelvis. 
The  rupture  of  the  bladder  due  to  fracture  of  the  pelvis  is  usually 
extraperitoneal  and  it  is  situated  on  its  anterior  surface. 

On  account  of  the  fracture  the  patient  can  not  walk.      Rup- 
ture   of   the    bladder    itself   might    occasion    inability   to    walk, 
at   least  any  long   distance.     There  is   great   hypogastric   pain, 
frequent  desire  to  micturate  and  inability  to  pass  urine.      A  few 
drops  of  bloody  fluid  escape  from  the  meatus.      Dullness  may 
be   present  in   the   lower  abdomen   and    loins.      Soon  after  the 
accident,   if   not  immediately,  there   is   great  prostration.      Evi- 
dences of  shock  are  seen  in  the  pallor  of  the  face,  the  anxious 
expression,  the  feeble  pulse,  the  cold,  clammy  skin,  and  feeble 
voice.      The  abdomen  becomes  distended,  the  temperature  rises, 
and  delirium,  coma,  and  death  follow  with  certainty  unless  opera- 
tive   interference    has    relieved    the    condition    at   a   very   early 
hour  after  the  accident.      The  patient  dies  from  shock,  hemor- 
rhage, or  septic  peritonitis.      If  the  patient  is  seen  soon  after  the 
accident,  before  untoward  symptoms  have  appeared,  and  has  not 
micturated  for  some  little  time,  he  should  be  catheterized.      An 
empty  bladder  will  be  found  or  a  small   amount  of  bloody  fluid 
will  be  withdrawn,  which   rather  confirms  the  other  evidences  of 
ruptured    bladder.      If  there   is   doubt  as  to  the  rupture  of  the 
bladder,  the  symptoms  should  be  watched.      The  symptoms  of 
rupture  may   be   masked  or  delayed   by  the  associated   lesions. 
The  urine  may  be  tinged  with  blood  because  of  a  contusion  of 
the  bladder.      The  catheter  may  be  passed  through  the  bladder- 
wall,  and  be  felt  to  enter  the  abdominal  cavity,  evacuating  bloody 
fluid.      All    fluid    having   been   removed    from   the   bladder,  if  a 
measured   amount   of   sterile   water  is   injected   into   it,   and    all 
that  was  injected  does  not  return,  presumption  of  rupture  of  the 
bladder  is  very  great.      Under  such  circumstances  the  dull  area 
in   the    groins    and    lower  abdomen   of   extraperitoneal    rupture 
will   be  increase!  1. 

Exploratory  laparotomy  should  be  done,  and  it  the  extra- 
vasation proves  to  be  extraperitoneal,  drainage  of  this  area  is 
demanded.     Temporary  drainage  of  the  bladder,  cither  urethral 


PROGNOSIS  105 

or  through  perineal  section,  will  be  needed  to  permit  healing 
of  the  bladder  wound.  The  bladder  wound  is  usually  inacces- 
sible to  suture  in  these  cases. 

Prognosis. — A  guarded  prognosis  should  always  be  given  in 
any  case  of  fracture  of  the  pelvis.  Fractures  of  the  iliac  crest 
ordinarily  recover  in  a  few  weeks.  In  fractures  complicated  by 
rupture  of  the  bladder  or  bowel  the  prognosis  is  extremely 
"■rave. 


CHAPTER  VII 
FRACTURES  OF  THE  CLAVICLE 

Anatomy. — The  clavicle  is  subcutaneous  throughout  its 
whole  length  (see  Fig.  114).  The  acromioclavicular  joint  is  at 
its  outer  end.  The  sternoclavicular  joint  is  at  its  inner  end. 
The  clavicle  lies  in  a  muscular  plane   made   up  of  the  trapezius 


Fig.  113. — Normal  left  clavicle  viewed  from  above. 


Fig,  11 1.     Muscles  arising  from  and  attached  to  the  clavicle,  showing  the  muscular  plane  in 

which  the  •  l.u  icle  lies.    X  points  to  the  coracoid  process. 

and  sternocleidomastoid  muscles  abi  >ve,  and  the  deltoid,  pect  oralis 
major,  and  subclavius  muscles  below  (see  Fig.  1  14).  It  is  impor- 
tant to  n-i  ognize  the  situation  and  the  direction  of  the  acromio- 

IO() 


SYMPTOMS 


IO/ 


clavicular  joint  in  order  to  discriminate  between  a  fracture  of  the 
outer  end  of  the  clavicle  and  one  of  the  acromial  process.  It  is 
likewise  important  intelligently  to  palpate  the  normal  shoulder,  to 
determine  that  the  acromial  process  does  not  form  the  outer  limit 
of  the  shoulder,  but  that  it  is  formed  by  the  greater  tuberosity  of 
the  humerus. 

Symptoms. — The  common  seat  of  fracture  is  in  the  middle 
third  of  the  bone  (see  Figs.  1 15-1 18  inclusive).  The  shoulder, 
having  lost  the  support  of  the  clavicle,  falls  forward  and  drops 
inward,  consequently  the  outer  fragment  that  moves  with  the 
shoulder  drops  below  the  inner  fragment  and  overlaps  it  in 
front.      The  inner  fragment,  having  attached  to  it  the  sternocleido- 


Fig.  115. —  Fracture  at  the  inner  and 
middle  thirds  .of  right  clavicle  from  above 
(Warren  Museum,  specimen  1214). 


Fig.  116. — Fracture  toward  middle  of 
ciavicle,  a  little  to  the  inside  (common 
site).  Right  clavicle  from  above  (Warren 
Museum,  specimen  987). 


Fig.  117. — Fracture  at  the  outer  and 
middle  thirds  of  left  clavicle  from  above 
(Warren  Museum,  specimen  987). 


Fig.  118.— Fracture  at  the  outer  end  of 
clavicle.  Left  clavicle  from  above  (War- 
ren Museum,  specimen  7900). 


mastoid  muscle  and  being  comparatively  free  to  move,  is  drawn 
slightly  upward.  The  attitude  of  the  patient  is  characteristic 
(see  Figs,  i  19,  1  20)  :  he  stands  with  the  head  inclined  to  the  in- 
jured side,  thus  relaxing  the  pull  of  the  sternocleidomastoid  muscle 
upon  the  inner  fragment.  The  shoulder  upon  the  side  fractured 
is  depressed  ;  the  elbow  and  forearm  upon  this  same  side  are  sup- 
ported by  the  well  hand.  This  is  the  attitude  of  greatest  com- 
fort. The  shoulder — /'.  e.,  the  space  between  the  base  of  the 
neck  and  the  greater  tuberosity  of  the  humerus — is  shortened 
upon  the  injured  side  (see  Fig.  131).  If  the  fracture  lies  within 
the  limit  of  the  coracoclavicular  ligament  or  outside  of  it,  there 
will  be  no  appreciable  displacement  (see  Fig.  121).      The  diagnosis 


Kij;.  119. — Case:  Comminuted  fracture  of  the  left  clavicle.     Attitude  characteristic  ;  deformity 
visible;  wired  (Mixter). 


..—Attitude  characteristic  of  a  recent  fracture  of  the  right  clavicle. 

b       C     d 


i,         :.     Diagram  of  the  ligaments  attached  to  and  neai  the  clavicle  on  its  undei  surface: 
a .  Rhomboid  ;  b,  conoid;  c,  trapezoid  j  d,  coraco-a al. 

10S 


TREATMENT    IN    ADULTS  1 09 

under  these  circumstances  will  be  difficult.  Localized  pain  and 
the  disability  of  the  arm  will  suggest  the  lesion  present. 

Fracture  of  the  Clavicle  in  Childhood. — More  than  one-third 
of  all  fractures  of  the  clavicle  occur  in  children  under  five  years 
of  age.  A  trivial  injury  is  the  usual  cause  of  the  fracture.  A 
little  child  may  fall  from  a  low  chair  or  out  of  bed  and  fracture 
the  bone.  The  fracture  is  most  always  incomplete  or  green- 
stick. 

The  child  cries  upon  moving  the  arm.  Lifting  the  child 
by  placing  the  hands  in  the  armpits  causes  pain.  The  arm  of 
the  injured  side  may  be  used  as  naturally  as  the  other  or  there 
may  be  some  disability,  perhaps  simply  a  disinclination  to  use 
the  arm.  If  the  fracture  is  greenstick,  a  tender  swelling 
appears  at  the  seat  of  the  fracture.  If  the  fracture  is  complete, 
an  unevenness  will  be  felt  at  the  seat  of  fracture  according  to  the 
amount  of  displacement.  The  displacement  is  usually  slight  in 
childhood.  The  characteristic  attitude  seen  in  adults  (see  Figs. 
119,  120)  is  much  less  marked  in  children,  and  if  the  fracture 
is  greenstick,  there  is  no  tilting  of  the  head  and  depression  of  the 
shoulder.  If  the  child,  as  so  often  occurs,  persistently  holds  the 
head  so  that  a  careful  examination  is  impossible,  then  it  is  best 
to  place  the  child  on  its  back,  and  while  its  legs  and  arms  are  held 
firmly,  the  head  and  shoulder  may  be  gently  and  gradually  sepa- 
rated.     The  examination  can  then  be  completed. 

Treatment  in  Adults. — The  displacement  should  be  corrected 
and  the  corrected  position  maintained  (see  Figs.  122,  123).  The 
indications  are  to  carry  the  shoulder,  and  with  it  the  outer  frag- 
ment, upward,  outward,  and  backward. 

The  Recumbent  Treatment. — The  displacement  is  most  satis- 
factorily corrected  by  the  patient  lying  recumbent  upon  a  firm 
mattress.  The  weight  of  the  shoulder  in  this  position  does  not 
impede  reduction,  as  in  the  upright  position,  but  assists  it.  A 
firm  and  small  pillow  should  be  placed  between  the  shoulders. 
The  shoulders  fall  backward  of  their  own  weight  over  the  pillow 
carrying  the  outer  fragment  backward  at  the  same  time.  Pad- 
ding of  the  fragments  of  the  clavicle,  the  application  of  pressure 
to  the  elbow,  may  be  more  satisfactorily  accomplished  in  the 
recumbent  than  in  the  upright  position.      LTnion  ordinarily  occurs 


Fig.  122. — Fracture  ol  the  clavicle.  Method  of  correction  of  falling  inward  and  downward 
of  shoulder,  in  overriding  of  fragments  previous  to  the  application  of  the  modified  Sayre 
dressing. 


Fig.  i.'.-,.    Fracture  of  the  clavicle.    Same  as  figure  122.    Posterior  view,  showing  extreme 
backward  position  ol  shoulders. 


Mb  ■ 

s 

'  -4G&S'''  \ 

■   i 

ll 

■S^ 

Fig.  124. — Fracture  of  the  left  clavicle.  Mod- 
ified Sayre  dressing.  Towel  circular  of  upper  arm 
held  by  adhesive  plaster.  Adhesive-plaster  strap 
ready. 


Fig.  125. — Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  applied. 
Shoulder  carried  backward.  Fixed  point 
established  above  middle  of  humerus. 


Fie:.  126. — Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  applied. 
Second  adhesive-plaster  strap  being  ap- 
plied. Hole  in  plaster  for  olecranon  visible. 
Note  pad  for  wrist  and  folded  towel  pro- 
tecting skin  of  arm  and  chest. 


Fig.  127. — Fracture  of  the  left  clavicle. 
First  and  second  adhesive-plaster  straps 
applied.  Pad  in  left  hand.  Shoulder 
pulled  backward  and  elevated. 


112  FRACTURES  OF  THE  CLAVICLE 

within  three  weeks.  At  the  time  of  union  or  shortly  after  the 
patient  may  be  allowed  up  with  a  simple  retentive  dressing,  a 
sling,  and  a  swathe.  The  bed  treatment  is  hard  to  enforce  because 
the  fracture  is  the  cause  of  so  little  real  permanent  disability. 
If  there  is  much  displacement  and  deformity  can  not  be  corrected 
and  held  properly,  the  bed  treatment  is  indicated.  In  the 
simultaneous  fracture  of  both  clavicles  the  recumbent  bed 
treatment  is  the  best  (see  Operative  Treatment  of  Fracture  of 
the  Clavicle). 

The  Modified  Sayre  Dressing. — The  shoulder  and  arm  are 
unwieldy  in  adults.  It  is,  therefore,  necessary  in  treating  a  frac- 
ture of  the  clavicle  by  an  ambulatory  method  to  secure  a  very 
firm  hold  upon  the  shoulder  in  order  to  maintain  the  clavicular 
fragments  in  a  good  position. 

The  modified  Sayre  adhesive-plaster  dressing  is  the  best.  It 
is  applied  as  follows  :  Provide  three  strips  of  adhesive  plaster, 
four  inches  wide,  and  long  enough  to  extend  once  and  a  half 
around  the  body.  The  skin  surfaces  that  are  to  come  in  con- 
tact— namely,  the  axilla  and  chest  and  forearm — are  separated 
by  compress  cloth  and  powder.  A  dressing  towel,  folded  like 
a  cravat,  is  snugly  pinned  high  up  about  the  upper  arm  (see 
Fig.  124).  This  towel  may  be  held  neatly  by  a  strip  of  adhe- 
sive plaster.  One  end  of  the  first  adhesive  strap  is  fastened 
loosely  about  the  towel-protected  arm  with  a  safety-pin.  While 
an  assistant  holds  the  shoulder  well  back  the  arm  is  carried  back- 
ward, and  held  by  the  fastening  of  the  first  adhesive  strap  about 
the  body  (see  Fig.  125).  This  affords  a  fixed  point  at  the  middle 
of  the  upper  arm.  The  second  strap,  with  a  hole  in  it  to  receive 
the  point  of  the  elbow,  is  started  upon  the  posterior  surface  ot 
the  injured  shoulder  (see  Fig.  126)  and  carried  under  the  elbow 
of  the  injured  side  and  over  the  well  shoulder  (see  Fig.  127). 
The  forearm  is  Hexed,  and  rests  upon  the  chest.  In  applying 
this  second  strap  the  shoulder  is  raised  and  the  elbow  is  carried 
forward,  thus  forcing  the  shoulder  slightly  upward  and  backward 
of  the  fixed  point  used  as  a  fulcrum  (see  Fig.  1  2<X).  A  third  strap 
may  be  placed  around  the  trunk  and  arm  to  steady  all  in  good 
position.  Over  this  dressing  may  be  put  a  Yelpeau  bandage 
for   the    comfort  of  the    support  which  it  affords  (see  Fig.   129). 


TREATMENT    IN    CHILDREN 


I  I 


The  adhesive  plaster  may  be  covered  with  bits  of  gauze  bandage, 
in  part  to  protect  the  skin  from  undue  chafing,  sufficient  plaster 
surface  remaining  uncovered  to  prevent  the  straps  from  slipping. 
Occasionally,  pads  (see  Fig.  130)  upon  the  clavicle  may  be  used 
to  correct  the  deformity,  but  the  bone  is  so  subcutaneous  that 
the  skin  can  not  bear  great  pressure  without  damage.  If  pads 
are  used,  they  must  receive  frequent  inspection. 


Fig.  12S. — Fracture  of  the  right  clavicle. 
Modified  Sayre  dressing.  Posterior  view. 
Shoulder  elevated  and  pulled  backward. 
Folded  towel  seen  in  axilla  for  protection  to 
skin. 


Fig.  129. — Fracture  of  the  clavicle.  Method 
of  application  of  a  Velpeau  bandage.  Note  the 
order  and  direction  of  the  turns  I,  2,  3,  4,  and  5. 
Note  position  of  the  forearm  and  arm  of  the  unin- 
jured side. 


Treatment  in  Children. — The  skin  of  the  child  must  be  pro- 
tected by  powder  and  careful  drying  before  the  arm  is  done  up. 
If  it  is  a  greenstick  fracture  and  there  is  slight  deformity,  this 
deformity  should  be  corrected  by  pressure  with  the  thumbs.  An 
anesthetic  should  be  used.  After  the  deformity  is  corrected  and 
in  cases  without  deformity  it  is  necessary  simply  to  restrain  the 
movements  of  the  arm  for  two  weeks.  This  is  best  accomplished 
by  a  cotton  swathe  about  the  body  and  upper  arm,  held  by  straps 


H4 


FRACTURES    OF    THE    CLAVICLE 


over  the  shoulders  and  by  a  cravat  sling.  In  warm  weather  and 
also  in  cool  weather,  for  that  matter,  the  arm  is  to  be  inspected 
frequently,  as  often  as  every  third  day,  when  all  the  dressings 
are  removed,  the  parts  bathed  with  soap  and  warm  water,  pow- 
dered, and  the  simple  retentive  dressing  reapplied.  With  this 
care  only  can  chafing  be  avoided.  If  it  is  a  complete  fracture, 
the  modified  Sayre  adhesive-plaster  dressing  should  be  used  as  in 


PiK.  130.— Fracture  of  the  clavicle  and  subluxation  of  the  acromioclavicular  joint.  Notice 
elevation  of  shoulder  by  pressure  on  the  Hexed  elbow  and  counterpressure  on  the  clavicle  by 
a  bandage  and  a  pad  1     1  placed  internal  to  the  acromioclavicular  joint. 


adults.  The  skin  is  to  be  carefully  protected,  and  the  dressing 
most  assiduously  watched.  It  requires  but  forty-eight  hours  for 
great  chafing  to  occur  with  the  resulting  discomfort  and  the  slow 
healing  which  often  results.  If  union  is  firm  after  two  weeks  or 
two  weeks  and  a  half,  the  plaster  dressing  should  be  removed  and 
the  shoulder  put  up  in  a  simple  retentive  swathe  and  sling,  at 
first,  inside   the  clothes;    after  three   weeks,  outside  the  clothes. 


Fig.  131. — Fracture  of  the  right  clavicle.     Shortening  of  the  shoulder. 


Fig.  132. — Fracture  of  the  left  clavicle.     Little  displacement,  but  excessh  e  (.alius 

"5 


I  1 6  FRACTURES    OF    THE    CLAVICLE 

In  very  active  children  the  sling  should  not  be  removed  until  four 
weeks  have  elapsed.  Massage  should  be  given  to  the  forearm, 
elbow,  and  shoulder  after  the  first  week,  together  with  passive 
motion  of  the  elbow.  In  both  children  and  adults  the  adhesive- 
plaster  dressing  should  be  reapplied  at  least  once  every  ten  or 
twelve  days.  If  the  dressing  chafes  or  slips,  it  may  need  more 
frequent  renewal. 

Prognosis. — Useful  arms  and  shoulders  usually  result  after 
fracture  of  the  clavicle.  Almost  all  complete  fractures  of  the 
clavicle  with  displacement  of  fragments,  after  repair  has  taken 
place,  show  unmistakable  evidences  of  deformity  at  the  seat  of 
fracture,  of  shortening  of  the  width  of  the  shoulders,  and  in 
many  instances  in  children  of  a  slight  lateral  deformity  of  the 
spinal  column  (see  Figs.  131,  132).  Fractures  within  the  coraco- 
clavicular  ligament  having  little  displacement  of  fragments  show 
no  resulting  deformity.  Very  great  deformity  does  not  preclude 
a  useful  arm.  An  ununited  fracture  of  the  clavicle  is  unusual  ; 
it  may  exist  and  cause  no  especial  inconvenience  ;  it  may  be 
unknown  to  the  patient.  An  ununited  fracture  of  the  clavicle 
with  considerable  callus-formation  may  simulate  malignant  dis- 
ease of  the  bone.  Laboring  men  are  rarely  kept  from  their 
work  more  than  two  months.  Fractures  of  the  clavicle  in 
young  children,  if  carefully  treated,  should  unite  with  practical!}' 
no  deformity  or  disability.  Greenstick  or  incomplete  fractures 
may  show  a  general  bowing  of  the  whole  bone,  which  it  has 
been  impossible  to  correct. 

Operative  Treatment. — In  recent  fractures  :  If  there  is  great 
displacement  which  can  not  be  held  reduced,  if  sharp  fragments 
threaten  vessels  or  nerves,  if  there  is  pressure  upon  either  nerves 
or  blood-vessels,  if  the  fracture  is  a  comminuted  one,  and  if  the 
bone  is  fractured  in  two  or  more  places  (multiple  fractures),  it  is 
wise  to  consider  operative  measures.  The  fragments  can  be 
exposed,  replaced,  and  held  in  position  by  suturing.  Good 
results  follow  this  treatment.  After  operation  for  fracture  of  the 
clavicle  a  simple  retentive  dressing  of  a  swathe  and  cravat  sling 
will  lie  needed.      It  should  be  worn  for  at  least  three  weeks. 

In  Ununited  Fractures. — If  the  cause  of  delayed  union  of  the 
fracture  is  a  misplaced  bony  fragment,  an  interposed  strip  of  fascia 


OPERATIVE    TREATMENT  WJ 

or  periosteum,  or  an  interposed  subclavius  muscle,  operative 
interference  may  be  undertaken  with  a  reasonable  expectation  of 
securing  a  good  result.  If,  on  the  other  hand,  nonunion  has 
existed  for  a  long  period  (a  year  or  more),  it  is  highly  probable 
that  the  ends  of  the  fragments  will  be  so  attenuated  that  refresh- 
ing these  ends  for  suture  would  shorten  the  fragments  to  such 
an  extent  that  suture  would  be  impracticable. 


CHAPTER  VIII 
FRACTURES  OF  THE  SCAPULA 

The  spine  and  acromial  process,  the  coracoid  process,  and  the 
vertebral  and  axillary  borders  of  the  scapula  can  be  palpated  with 
comparative  accuracy.  Fracture  of  the  scapula  is  of  rather 
unusual  occurrence,  and  always  follows  great  violence  (see  Fig. 

1 33)- 

Fracture  of  the  body  of  the  scapula  is  transverse  between 

the  axillary  and   vertebral    borders  or  comminuted    in   various 

directions  (see  Figs.   134,   135). 

Crepitus,  abnormal  mobility,  local  swelling,  and  tenderness  are 
present.  Pain  is  felt  upon  attempting  to  abduct  the  arm.  It 
may  be  impossible  to  raise  the  arm  to  the  head. 

Fracture  of  the  Acromial  Process  of  the  Scapula. — The 
epiphysis  of  the  acromion  unites  with  the  scapula  about  the  twen- 
tieth year.  If  there  is  a  fracture  present,  and  not  a  separation 
of  the  epiphysis,  which  sometimes  occurs,  the  line  of  fracture  is 
ordinarily  outside  the  acromioclavicular  joint.  A  fracture  may 
occur  through  the  acromion  nearer  to  the  spine  of  the  scapula. 

Localized  pain,  swelling,  and  tenderness,  and  a  flattening  of 
the  shoulder  are  present.  Crepitus  may  at  times  be  felt.  If  the 
fracture  is  inside  the  acromioclavicular  joint,  the  flattening  of  the 
shoulder  will  be  considerable.  The  head  of  the  humerus  is  felt 
in  the  glenoid  cavity,  thus  ruling  out  a  dislocation. 

Fracture  of  the  neck  of  the  scapula  is  most  unusual.  If 
present,  it  may  be  mistaken  for  a  dislocation  of  the  humeral 
head. 

The  acromial  process  is  prominent.  The  upper  arm  is  length- 
ened. (  )n  lifting  the  arm  forcibly  upward  with  the  elbow  flexed, 
the  deformity  is  corrected,  and  crepitus  is  detected.  The  de- 
formity recurs  if  this  upward  pressure  is  removed.  The  reap- 
pearance of  the  deformity  and  the  crepitus  serve  to  distinguish 

IIS 


TREATMENT    OF    FRACTURES    OF    THE    SCAPULA  I  I  9 

this  injur\-  from  a  dislocated  shoulder.  In  a  thin  person  palpa- 
tion of  the  edges  of  the  glenoid  cavity  itself  will  prove  rather 
satisfactory ;  the  crepitus  and  abnormal  mobility  can  thus  In- 
more  accurately  located. 

Treatment   in  General. — Immobilization  of  the   whole   upper 


Fig.  133. — Normal  scapula.     Anterior  and  posterior  views. 


Fig.  134. — Fracture  of  the  body  of  the 
scapula  Bony  union  with  moderate  displace- 
ment (Warren  Museum,  specimen  81 1 1 ) . 


Fig.  135.— Multiple  fractures  of 
scapula.  Railroad  accident.  Man, 
forty-three  years  of  age.  Lived  one 
day  (Warren  Museum,  specimen  6028). 


extremity,  except  the  forearm  and  hand,  is  necessary.      Localized 
pressure  may  assist  in  retaining  fragments  in  place. 

If  there  is  fracture  of  the  body  of  the  scapula,  the  forearm 
should  be  flexed  to  a  right  angle  and  held  in  a  sling.  The 
skin-surfaces  coming  in  contact  should  be  protected  by  powder 


I  20  I- KACTURES  OF  THE  SCAPULA 

and  compress  cloth.  A  swathe  of  cotton  cloth  should  be  fas- 
tened about  the  upper  arm  and  trunk.  If  the  cloth  swathe  is  not 
sufficient  to  hold  the  scapula  steady,  a  swathe  of  adhesive 
plaster  should  be  used,  broad  enough  to  extend  from  the  acro- 
mion to  the  elbow. 

Fracture  of  the  Acromial  Process  :  The  skin-surfaces  must 
first  be  protected  from  chafing.  The  forearm  being  flexed,  pres- 
sure upward  should  be  made  upon  the  elbow,  so  as  to  lift  the 
arm  and  relax  the  pull  on  the  small  acromial  fragment.  At  the 
same  time  counterpressure  is  made  upon  the  inner  fragment  and 
incidentally  upon  the  inner  shoulder  (see  Fig.  130).  This  pres- 
sure and  counterpressure  will  hold  the  part  reduced.  The 
bandage  must  be  inspected  frequently  each  day,  in  order  to 
detect  and  to  relieve  too  great  pressure  upon  the  elbow  and  bony 
parts  of  the  shoulder. 

Union  will  take  place  in  from  three  to  four  weeks.  It  is  ex- 
tremely difficult  to  maintain  the  reduction  of  the  fragment  of  the 
acromion  by  any  apparatus.  The  one  previously  suggested 
meets  the  indications  better  than  any  other.  Massage  will 
materially  assist  in  hastening  the  absorption  of  blood  and  will 
relieve  pain.  No  very  great  functional  disability  results  if  union 
occurs  with  bony  displacement. 


CHAPTER   IX 
FRACTURES  OF  THE  HUMERUS 

FRACTURES  OF  THE  UPPER  END  OF  THE  HUMERUS 
Anatomy. — The  clavicle  may  be  felt  throughout  its  entire- 
length  from  sternum  to  acromion.  The  acromial  process  of  the 
scapula  articulates  with  the  outer  end  of  the  clavicle.  This 
acromioclavicular  joint  has  an  anteroposterior  direction,  and  if 
the  line  of  this  joint  is  continued  anteriorly,  it  will  pass  down 


Fig.  136. — View  of  bones  of  the  shoulder  from  above.  Notice  acromioclavicular  joint,  its 
relations  to  bicipital  groove  and  coracoid  process.  The  point  of  the  shoulder  is  made  by  the 
great  tuberosity  of  the  humerus. 


the  front  of  the  upper  arm  (see  Fig.  136).  The  outer  edge  of 
the  acromion  is  continuous  downward  and  backward  with  the 
spine  of  the  scapula.  The  great  tuberosity  of  the  humerus 
projects  beyond  the  acromial  process,  and  is  covered  by  the 
deltoid  muscle.  The  point  of  the  shoulder  itself  is  made  by  the 
humerus  and  not  by  the  acromion  (see  Figs.   136,  138). 


I  2. 


FRACTURES    OF    THE    HL'MFKL'S 


Examination  of  the  Shoulder. — The  uninjured  shoulder 
should  be  examined  before  the  injured  shoulder.  In  injuries 
doubtful  in  character,  associated  with  much  swelling  of  the 
shoulder,  and  which  are  painful  upon  gentle  manipulation,  the 
examination    should    be    made    with    the  aid    of  an  anesthetic. 


Head  of  humerus. 
Glenoid  fossa. 


Fig.  H7- — Transverse  section  of  trunk,  showing   obliquity  of  shoulder-joint   in   relation  tt 
chest,  and  the  inclination  of  the  glenoid  cavity. 


Coracoid  process.        Clavicle. 


Acromial  process 
of  scapula. 


Head  of  humerus. 


Fig.  i;,s.  — Relations  of  bones  to  surfaces  of  shoulder  region.     Great  tuberosity  of  humerus 
s  beyond  the  acromial  process  of  scapula.     Relations  of  coracoid  to  clavicle  and  head 
of  humerus  (compare  with  Fig.  144). 


<  rreat  swelling  suggests  great  trauma  ;  absence   of  all  swelling 
appreciable  to  the  eye  suggests  slight  trauma. 

For  the  examination  the  patient  should  be  sealed  upon  a 
rather  high  stool,  so  that  the  shoulder  comes  to  an  easy  level  for 
manipulation.  The  shoulder  should  be  grasped,  so  that  the  head 
of  the  humerus  can  be  felt  between   the   fingers   and  thumb  of 


Fig.  139.— Examination  of  shoulder.     Method  of  palpating  head  of  humerus  with  thumb  and 
ringers.     Elbow  grasped  by  other  hand. 


Fig.  140.— Examination  of  shoulder.     Movements  of  the  shoulder.     Normal  maximum  abduc- 
tion.    Notice  method  of  grasping  head  of  humerus. 


^4 


FRACTURES    OF    THE    HUMERUS 


one  hand  pressed  under  the  spinous  and  acromial  processes. 
The  other  hand  should  grasp  the  flexed  elbow  firmly,  in  order 
to  make  the  necessary  movements  at  the  shoulder-joint  (see 
Fig.  1 39).  If  the  head  of  the  humerus  is  intact  and  in  its  normal 
place,  it  will  be  felt  to  move  with  the  shaft  of  the  humerus,  as 
upon  the  uninjured  side.  All  the  normal  movements  of  the 
shoulder-joint  should  be  made  passively  and  actively — namely, 
the  movements  of  abduction,  adduction,  forward  and  backward 


Fig.  141.— Examination  of  shoulder.     Maximum  adduction.     The  bend  of  the  elbow,  when 
the  forearm  is  Hexed  to  a  right  angle,  comes  to  the  median  line  of  trunk. 


suing,  and  rotation  (see  Figs.  140,  141,  142).  Those  move- 
ments which  are  painful  and  limited  should  be  carefully  noted. 
Unless  the  normal  individual  standard  of  movement  is  known,  as 
determined  by  examination  of  the  well  shoulder,  there  can  be  no 
definite  interpretation  of  the  conditions  existing  in  the  injured 
shoulder.  The  condition  of  the  circulation  and  the  presence  of 
paresis  or  paralysis  in  the  limb  should  be  observed.      The   shaft 


EXAMINATION    OF    THE    SHOULDER 


12 


of  the  humerus  should  be  measured  :  the  measurement  best  taken 
is  the  distance  between  the  edge  of  the  acromial  process  and  the 
external  condyle  of  the  humerus.  The  patient  should  be  seated 
with  the  elbow  at  the  side  if  possible,  and  flexed  to  a  right  angle 
(see  Fig.  143).  The  forearm  should  rest  on  the  thigh  of  the 
same  side.  The  direction  of  the  long  axis  of  the  humerus 
should  be  carefully  noted. 

The  coracoid  process  of  the  scapula  in  all  injuries  to  the  shoul- 


Fig.    142. — Examination   o(    shoulder.      Maximum    outward    rotation.      Notice   position   ot 

examining  hands. 


der  should  be  palpated,  for  a  knowledge  of  its  position  assists  in 
locating  the  head  of  the  humerus  intelligently  (see  Fig.  144).  The 
examiner  should  stand  in  front  of  the  patient,  and  place  the  left 
hand  upon  the  right  shoulder  and  the  right  hand  upon  the  left 
shoulder,  the  hands  being  open.  The  thumb  should  fall  below 
the  clavicle  a  full  finger's-  breadth,  when  the  end  of  the  thumb  will 
touch  the  coracoid.  It  is  generally  possible  to  feel  the  coracoid 
even  in  very  stout  people  and  when  much  swelling  is  present. 


126 


FRACTURES    OF     THE    HUMERUS 


Diagnosis. — It  is  sometimes  impossible  to  determine  the  exact 
lesion  following  an  injury  to  the  shoulder.  Anesthesia  and  the 
Rontgen  ray  are  invaluable  aids  to  diagnosis.  It  is  of  the  first 
importance  to  know  whether  the  head  of  the  humerus  is  in  the 
glenoid  cavity  or  whether  it  is  dislocated  ;  this  is  determined  by 
palpation  and  by  noting  the  direction  of  the  long  axis  of  the 
humerus.  It  is  next  in  importance  to  learn  whether  there  is  a 
fracture  of  the  humerus.      If  the  humeral  head  rotates  with  the 


Fig.  143. — Method  of  measur- 
ing the  length  of  the  shaft  of  the 
humerus  from  the  acromial  pro- 
cess to  the  external  condyle. 


Fig.  144. — Examination  of  shoulder.  Palpating 
the  coracoid  processes.  Note  the  position  of  the  hands 
and  thumbs. 


shaft,  there  is  probably  no  fracture  unless  there  is  one  with  impac- 
tion. If  the  humeral  head  does  not  rotate  with  the  shaft,  then 
there  is  a  fracture.  If  crepitus  is  present,  the  diagnosis  is  con- 
firmed. After  injury  to  the  shoulder  the  following  fracture  lesions 
may  be  present,  and  are  to  be  considered  : 

fracture  of  the  anatomical  neck  of  the  humerus. 
Separation  of  the  upper  humeral  epiphysis. 
I  racture  of  the  surgical  neck  of  the  humerus. 


DIFFERENTIAL    DIAGNOSIS  12/ 

In  any  one  of  these  instances  a  dislocation  of  the  humeral 
head  from  the  glenoid  cavity  may  exist  and  complicate  the  case. 

Simple  Dislocation  of  the  Humeral  Head,  Subcoracoid  (see 
Fig.  145). — The  attitude  is  characteristic :  the  affected  arm 
is  held  flexed,  with  the  elbow  away  from  the  side  and  the  arm 
rotated  inward.  The  anterior  axillary  fold  is  lowered  upon  the 
injured   side.      The   long  axis   of  the    shaft   of   the    humerus  is 


Fig.  145.  —  Dislocation  of  the  left  shoulder.  Note  the  flat  deltoid.  Prominence  under 
coracoid.  Direction  of  the  long  axis  of  the  humeral  shaft.  Lengthening  of  upper  arm.  Left 
nipple  lowered.     Anterior  axillary  fold  lowered. 


inclined  inward.  The  roundness  of  the  shoulder  is  flattened. 
The  acromial  process  is  prominent.  The  head  of  the  humerus 
is  out  of  the  glenoid  cavity,  and  most  often  lies  under  the  cor- 
acoid process.  The  elbow  can  not  be  brought  in  front  toward  the 
median  line,  nor  can  the  hand  of  the  injured  arm  be  placed  upon 
the  opposite  shoulder.  Active  and  passive  movements  at  the 
shoulder-joint  are  greatly  restricted.  Measuring  from  the  acro- 
mial process   to  the  external    epicondyle   of   the    humerus,   the 


128 


FRACTURES    OF    THE    HUMERUS 


upper  arm,  in  a  subcoracoid  dislocation,  is  lengthened.  A  soft 
crepitation  may  be  detected  in  manipulating  the  shoulder,  which 
simulates  bony  crepitus. 

Fracture  of  the  Anatomical  Neck  (see  Figs.  146,  147,  148, 
149,  150,  151). — This  is  rare.  It  occurs  in  elderly  people. 
Swelling  of  the  shoulder  is  evident.  Anesthesia  is  necessary 
for  a  careful  examination  with  deep  palpation.  There  is  thick- 
ening of  the  neck  of  the  bone.  Crepitus  will  be  felt  unless  the 
fracture  is  impacted.      There  will  be  pain  upon  moving  the  shoul- 


Fig.  146. — Fracture  of  the  anatomical  neck  of  the  left  humerus.  Atrophy  of  the  shoulder 
muscles.  Deformity  at  the  seat  of  the  fracture,  seen  a  little  below  acromial  process  upon  the 
anterior  surface  of  the  shoulder  just  inside  the  white  line. 


der.  Abnormal  mobility  may  be  felt  high  up  the  shaft  close  to 
the  head  of  the  bone.  This  fracture  lies  wholly  within  the  cap- 
sule of  the  joint. 

Separation  of  the  Upper  Epiphysis  (see  Figs.  152,  153,  154, 
155,  156). — The  separation  of  the  upper  humeral  epiphysis  will 
not  necessarily  open  the  joint  cavity,  for  the  capsular  ligament  is 
firmly  attached  to  the  epiphysis  and  the  synovial  membrane  is  but 
loosely  attached  to  the  diaphysis.  The  line  of  the  separation  of 
the  upper  epiphysis  <>f  the   humerus  begins  on  the  inner  side  of 


I )  I  K  !•'  I'.  K  E  X  X I A  L    I )  I A  G  N  OSI S 


[29 


the  head  of  the  bone  and  runs  across  almost  horizontal]}-,  rising 
toward  the  center  of  the  shaft,  and  ends  in  the  outer  side  of  the 
bone,  so  that  the  epiphysis  includes  the  tuberosities. 

This  happens  to  young  people,  but  never  after  the  twentieth 
year.  The  most  frequent  period  is  between  the  ages  of  nine  and 
seventeen  years.  Ordinarily,  the  upper  end  of  the  lower  frag- 
ment projects  forward   and   inward,   producing   a  characteristic 


Fig.  147. — Normal  right  shoulder.     Compare 
with  figure  148.    Same  case  as  figure  146. 


Fig.  148. — Fracture  of  the  anatomical  neck 
of  the  left  humerus.  Sharp  deformity  ante- 
riorly characteristic.  Compare  with  figures 
146  and  147. 


deformity.  The  head  of  the  bone  is  in  the  glenoid  fossa,  but 
rotated  by  the  muscles  attached  to  it  so  that  its  articular  surface 
looks  downward.  It  does  not  rotate  with  the  shaft.  The  crepi- 
tus is  of  a  softer  quality  than  in  cases  of  fracture — i.  c,  carti- 
laginous. Localized  pain  and  swelling  are  present.  A  puckering 
of  the  skin,  caused  by  the  hooking  of  the  lower  fragment  into 
the  skin,  is  characteristic  (see  Fig.  153).  Palpation  reveals  the 
upper  end  of  the  shaft.  A  high  lesion  near  the  joint  in  a  young 
9 


I — Shaft  of  1 


nimei  us. 


Fig.  149. —  Fracture  of  high  surgical  or  anatomical  neck  of  humerus.     Recovery  with  useful 
arm.     Slight  limitation  of  movements  only  (X-ray  tracing). 


Shaft  of  humerus. 


<  llenoid  cavity 
of  scapula. 


Fig.  150. — Fracture  of  the  anatomical  11a  k  ol  the  humerus  (X-ray  tra<  ing) 


Fig.  151.— Man,  sixty  years  of  age.  Fracture  of  anatomical  neck  of  humerus,  six  months 
previous  to  this  (X-ray  tracing).  Backward  swing  and  abduction  slightlv  limited,  otherwise 
normal  movements.     Useful  arm. 


Coracoid 
process.     Clavicle. 


Epiphyseal  line. 
Glenoid  fossa. 


Fig.  152. — Normal  shoulder,  showing  epiphysis  of  upper  end  of  humerus  1  X-ray  tracing!. 


131 


Fig  !53- — Separation  of  upper  epiphysis 
of  the  humerus  immediately  alter  the  acci- 
dent. Note,  especially,  position  of  upper 
arm  and  position  of  head,  and  deep  crease 
in  skin  made  by  the  catching  of  the  skin  in 
the  upper  end  of  the  lower  fragment.  Same 
as  figure  154. 


Kig.  154. — Separation  of  the  upper  epiphysis  ol 
the  humerus  (lelt).  Notice  shortening  of  the  upper 
arm.  Unusual  fullness  internal  and  above  normal 
position  for  head.     Same  as  figure  155, 


1- ig.  [55.-   Reparation  oi  the  upper  epiphysis  oi   the  left  humerus.    Notice  prom  in 
bi  low  normal  plai  e  for  humeral  head.    This  prominence  is  made  1>\  the  upper  end  ol  lower 
case  a    figure  153. 

I32 


156. — Fracture  of  high  surgical  neck,  or  separation  of  epiphysis  with  rotation  of  head 
(X-ray  tracing  of  figure  153). 


Epiphysis. 


Lower  fragment 

and  callus. 


Pig-  157. 


-Old    fracture  of  surgical   neck   high   up,   simulating 
(X-ray  tracing). 


true   epiphyseal  separation 


Head  ofhu-      L 

merus.  / 


Shaft  of  liu-     I 

merus. 


j.-jK.  158.— High  fracture  of  surgical  neck,  simulating  separation  of  the  upper  epiphysis  of 
the  humerus.  Displacement  of  lower  fragment  inward.  Old  fracture  unreduced  (X-ray 
tracing  I. 


\'\k-    159.— Impacted 

11  gii  .1    neck   and 
,11  set  tii  >n  1  Wai  nil 
Museum,  spei  imen  - 


Fig.  160. — Fracture  of  the  surgical  neck  of 
the  humerus.  Much  displacement.  Fibrous 
union  only  (Warren  Museum,  specimen  991 

'34 


Fig.  161. — Diagram  showing 
usual  displacement  in  fracture  of 
the  surgical  neck  of  the  humerus. 


Fig.  162. — Fracture  of  the  surgical  neck 
(X-ray  tracing). 


—  Head  of  humerus. 


Shaft  of  humerus 


Fig.   163. — Fracture  of  the  surgical  neck  of  the  humerus.     Displacement  of  the  shall  outwan 
Impossible  to  reduce  without  open  incision  (X-ray  tracing  1  (Eliot). 


135 


136 


FRACTURES    OF    THE    HUMERUS 


patient,  showing  displacement  forward  and  inward   of  the  shaft, 
is  very  suggestive  of  epiphyseal  separation. 

Fracture  of  the  Surgical  Neck  (see  Figs.  1 59,  160,  161,  162, 
163,  164). — Any  fracture  below  the  epiphyseal  line  of  the  upper 
end  of  the  humerus  and  well  within  the  upper  fourth  of  the 
shaft  of  the  bone  may,  for  all  practical  purposes,  be  regarded 
as  a  fracture  of  the  surgical  neck  of  the  humerus.  Fracture  of 
the  surgical  neck  is  the  common  fracture  of  the  upper  end  of 
the  humerus.  Fracture  of  the  anatomical  neck  is  most  often 
seen  in  the  aged.  Separation  of  the  upper  humeral  epiphysis 
occurs  in  youth. 


.  —  Upper  fragment. 
__  Lower  fragment. 


Fig.  164. — Fracture  of  surgical  neck  of  the  humerus.  Same  as  Bgure  163  after  reduction 
by  open  incision  and  wiring  with  silver  win-.  Recovery  as  to  motion  complete  (X-ray 
tracing)  (Eliot). 


The  head  of  the  bone  is  found  in  the  glenoid  cavity.  Passive 
movements  are  associated  with  pain,  and  elicit  crepitus  and 
abnormal  mobility  at  the  seat  of  fracture,  provided,  of  course, 
the  fracture  is  not  impacted.  The  arm  is  slightly  shortened. 
The  arm  is  held  flexed,  with  the  elbow  at  the  side. 

If  after  an  injur)- to  the  shoulder  no  positive  evidences  of  frac- 
ture or  dislocation  exist,  and  there  is  tenderness  and  localized 
swelling  about  the  joint,  and  motion  is  painful,  it  is  probable  that 
simply  a  contusion  exists. 


FRACTURES    OF    THE    UPPER    END    OF    THE    HUMERUS  I  3/ 

Treatment. — Fracture  of  the  Anatomical  and  the  Surgical 
Neck  and  Separation  of  the  Upper  Humeral  Epiphysis. — The 

importance  of  these  lesions  demands,  as  has  been  said,  an  exami- 
nation with  the  aid  of  an  anesthetic.  It  is  even  much  more  im- 
portant, however,  that  the  first  retentive  dressing  be  applied  with 
the  assistance  of  an  anesthetic.  Traction,  countertraction,  and 
manipulation  will  secure  coaptation  of  the  fragments.  To  hold 
these  fragments  securely  is  difficult.  To  hold  a  separation  of 
the  upper  epiphysis  in  position  may  be  impossible  without 
operative  assistance.  To  hold  any  one  of  these  fractures  without 
operative  interference  may  be  impossible. 

The  following  is  the  best  and  simplest  method  of  treatment  : 
The  upper  arm,  shoulder,  and  trunk  should  be  thoroughly- 
powdered.  The  hand,  forearm,  and  elbow  should  be  bandaged 
evenly,  smoothly,  and  firmly  with  a  bandage  of  flannel — not  cut 
on  the  bias.  A  V-shaped  pad  (with  the  apex  of  the  V  in  the 
axilla)  constructed  of  sheet  wadding  with  cardboard  outside  and 
covered  with  cotton  cloth,  should  be  placed  in  the  axilla  of  the 
injured  side  (see  Fig.  165).  This  pad  is  firm,  and  fitted  to  the 
trunk  in  order  to  support  the  inner  side  of  the  upper  arm 
(see  Fig.  166).  If  thought  wise,  a  thin  coaptation  splint  may  be 
placed  between  this  pad  and  the  inner  side  of  the  upper  arm 
for  more  direct  support.  The  forearm  is  held  flexed.  The 
shoulder  is  now  well  padded  with  one  layer  of  sheet  wadding.  A 
plaster-of-Paris  shoulder-cap  is  applied  so  as  to  cover  the  whole 
shoulder,  the  anterior  and  posterior  aspects  of  the  chest,  and  the 
outer  side  of  the  upper  arm  down  to  the  external  condyle  of  the 
humerus  (see  Fig.  167).  This  shoulder-cap  is  made  of  washed 
crinoline,  six  layers  thick,  into  which  has  been  rubbed  plaster-of- 
Paris  cream.  Its  exact  shape  and  extent  are  seen  in  the  plates. 
A  gauze  bandage  encircling  the  trunk,  arms,  and  shoulders  should 
be  used,  in  order  to  hold  the  upper  arm  at  the  side  and  closely 
applied  to  the  coaptation  splint  and  the  axillary  pad,  and  in  order 
to  secure  the  shoulder-pad  firmly  in  place.  Often  better  than  the 
plain  gauze  bandage  is  a  roller  bandage  of  unwashed  crinoline, 
which  is  applied  just  after  dipping  it  in  lukewarm  water  (see  Fig. 
168).  The  starch  of  the  crinoline  bandage  after  being  wet, 
stiffens  the  crinoline  as  it  dries  and  makes  a  particularly  firm  and 


Fiu -  165. — Fracture  of  the  upper  end  of  the  humerus.     No'e  hand,  forearm,  ami  elbow  ban 
da.^ed  ;  axillary  pad  and  strap. 


Fractun  of  the  upper  end  or  shaft  of  ihe  humerus.    Posterior  view.    Note  bandage 
to  forearm  and  elbow  ;  axillary  pad  and  strap.    Note  shape  of  axillary  pad. 


FRACTURES    OF    THE    ITI-'EK    END    OF    THE    HUMERUS 


139 


efficient  dressing.  A  towel  folded  thin  or  a  piece  of  compress 
cloth  should  be  placed  against  the  trunk  upon  the  well  side. 
Against  this  the  circular  turns  of  the  bandage  rest,  thus  causing 
less  discomfort  to  the  patient  than  if  they  bear  directly  upon 
the  chest.  The  forearm  is  supported  by  a  cravat  sling  (see  Fig. 
167).  By  this  method  of  immobilization  no  active  traction  is 
exerted  upon  the  lower  fragment.  The  weight  of  the  arm,  being 
unsupported  at  the  elbow,  exerts  slight  traction. 


Fig.  167.— Fracture  at  upper  end  of 
the  humerus.  Note  hand,  forearm,  and 
elbow  bandaged  ;  axillary  pad  and  strap, 
plaster-of-Paris  shoulder-cap,  sling. 


Fig.  168. — Fracture  at  upper  end  of 
humerus.  Arm  and  elbow  bandaged. 
Axillary  pad  and  shoulder-cap  in  position. 
Application  of  circular  bandage  to  trunk 
and  shoulder.     Sling  not  shown. 


On  account  of  the  absence  of  active  traction,  ambulatory  appa- 
ratus can  not  hold  a  fracture  of  the  shoulder  properly  if  there  is 
much  displacement;  particularly  if  the  fracture  is  oblique.  Am- 
bulatory apparatus  can  modify  muscular  action,  insure  quiet  and 
rest  to  the  part,  and,  except  in  the  instances  just  noted,  approxi- 
mately maintain  the  position  secured  by  manipulation  and  traction 
and  countertraction.  On  account  of  its  limitations,  therefore,  it  is 
important  that  apparatus  should  be  removed  at  regular  and  fre- 
quent intervals  and  that  the  whole  shoulder  should  be  examined 


I4O  FRACTURES    OF    THE    HUMERUS 

in  order  to  determine  errors  in   position  and,  if  possible,  to  cor- 
rect them. 

After=care  of  a  Fracture  of  the  Shoulder. — Ordinarily,  the 
great  swelling  associated  with  this  injury  disappears  in  two 
weeks.  As  the  swelling  subsides,  the  normal  contour  of  the 
shoulder  becomes  apparent  again.  It  is  necessary,  therefore,  to 
alter  the  shoulder  splint  and  to  apply  a  fresh  one.  When  the 
patient  wearing  a  shoulder-cap  lies  down,  there  is  a  tendency  for 
the  shoulder-cap  to  ride  up  and  away  from  the  shoulder.  This 
can  be  guarded  against  by  carrying  the  retaining  bandage  under 
the  firm  axillary  pad  and  well  over  the  shoulder.  Pressure 
points  should  be  carefully  watched,  and  the  pressure  removed. 
In  the  course  of  the  treatment  of  a  single  case  this  change  of 
dressing  will  have  to  be  made  two  or  three  times.  Union  will 
be  firm  in  from  three  to  four  weeks.  As  soon  as  union  is  firm, 
all  splints  may  be  omitted.  The  forearm  should  then  be  held 
by  a  sling  supporting  the  wrist.  At  night  it  will  be  wise  to 
apply  a  single  swathe  the  first  week  after  the  apparatus  is  left 
off  in  order  to  avoid  undue  motion  at  the  shoulder  during  sleep. 
In  these  injuries  about  the  shoulder-joint  passive  motion  should 
be  made  rather  early.  At  the  end  of  two  weeks  or  two  weeks 
and  a  half  repair  will  have  proceeded  far  enough  to  allow  of  the 
gentlest  movement  at  the  shoulder  without  causing  any  displace- 
ment of  fragments.  The  sooner  these  gentle  movements  can  be 
resumed  at  regular  and  short  intervals,  the  more  rapidly  the 
shoulder  will  improve.  The  common  occurrence  of  a  periarthritis 
after  an  injury  to  the  shoulder  emphasizes  the  necessity  of  mas- 
sage. It  should  be  begun  as  early  as  the  second  or  third 
week. 

Prognosis  and  Result. — In  young  subjects  a  useful  arm  will 
result  (see  Fig.  169).  At  first,  if  there  is  great  difficulty  in  main- 
taining the  reduction  of  the  fragments,  the  surgeon  will  expect  a 
poor  result,  but  if  he  persists  in  efforts  at  retention  and  uses 
passive  motion  early,  gradually  the  movements  of  the  arm  will 
return  and  to  a  surprising  degree.  In  people  past  middle  life 
there  usually  is  a  little  shortening  of  the  upper  arm  and  impair- 
ment in  some  few  of  the  movements  of  the  shoulder,  as  in  abduc- 
tion and  external   rotation.      In   individuals   over  fifty  years   old, 


FRACTURES    OF    THE    UPPER    EM)    OE    THE    HUMERUS  I4I 

excepting   those   with    rheumatism,    a   useful    but   not    a   strong 
shoulder  results  (see  Fig.   170). 

The  Prognosis  in  Separations  of  the  Epiphysis  :   Bony  union 


Fi".  169.— Young  adult.     Fracture  of  the  surgical  neck  of  the  humerus  (X-ray  tracing,  four 
°  years  after  ihe  accident).     Abduction  and  rotation  very  slightly  limited.     Useful  arm. 


Head  of 
\  humerus. 


Shaft  of 


humerus 


Fig  170.— Fracture.  Man  fifty-five  years  of  age.  High  surgical  neck  of  humerus.  At  the 
end  of  five  years  recovery  with  very  slight  limitation  of  motion  in  all  directions.  Abduction 
is  limited  nearly  one-half.    Useful  shoulder  (X-ray  tracing.     Massachusetts  General  Hospital, 

1021). 

is  to  be  expected.  If  there  is  little  or  no  displacement  of  frag- 
ments, complete  restoration  of  function  will  result.  If  there  is 
some    deformity    remaining    after    consolidation    of  the   injury, 


142  FRACTURES    OF    THE    HUMERUS 

the  usefulness  of  the  shoulder  is  ultimately  and  usually  restored. 
The  deformity  becomes  less  apparent  as  the  sharp  bony  coiners 
are  smoothed  off  by  the  newly  forming  callus.  It  is  not  to  be 
forgotten  in  considering  the  prognosis  after  all  shoulder  injuries 
that  much  of  the  persisting  disability  may  result  from  too  pro- 
longed immobilization  of  the  arm,  even  though  bony  displace- 
ment may  not  have  been  very  great.  The  growth  of  the  shaft 
of  the  humerus  in  length  proceeds  largely  from  the  upper  epiphy- 
sis. It  has  been  thought  by  many  that  an  arrest  of  growth 
of  the  humerus  will  follow  separation  of  this  upper  epiphysis.  It 
has  been  reported  to  have  occurred  in  eight  cases  but  in  no  others. 
In  several  of  these  cases  the  injury  to  the  shoulder  was  thought 
at  the  time  to  have  been  a  simple  contusion  or  sprain.  A  loss  of 
growth  is  not  likely  to  occur,  but  may  follow  injury  to  the  upper 
humeral  epiphysis. 

Oblique  Fracture  of  the  Surgical  Neck  with  Great  Dis= 
placement. — This  fracture  can  sometimes  be  held  by  placing 
the  patient  in  bed  upon  the  back  and  making  direct  traction  to 
the  upper  arm  and  countertraction  upon  the  shoulder  by  weight 
and  pulley.  If  the  fracture  can  not  be  easily  held  reduced,  it 
will  be  wise  to  make  the  closed  fracture  an  open  one  and  to  unite 
the  two  fragments  by  suture  (see  Figs.   163,   164). 

Fracture  of  the  Shoulder,  Surgical  or  Anatomical  Neck  of 
the  Humerus,  or  Separation  of  the  Upper  Epiphysis  of  the 
Humerus,  Together  with  a  Dislocation  of  the  Upper  Fragment. 
— The  head  of  the  humerus  is  found  in  an  unnatural  posi- 
tion and  it  fails  to  move  when  the  arm  is  rotated.  This  is 
generally  thought  to  be  an  unusual  accident,  but  by  careful  ex- 
amination man)'  of  these  cases  may  be  detected.  During  the 
attempt  at  reduction  of  a  dislocated  shoulder,  fracture  of  the 
humeral  shaft  is  liable  to  occur.  Among  many  cases  of  frac- 
ture of  the  surgical  neck  the  fracture  occurred  fifty-nine  times 
while  an  attempt  at  reduction  of  a  dislocation  of  the  shoulder  was 

being  made. 

Treatment. — Obviously,  attempts  at  reduction  by  manipula- 
tion in  the  usual  way  will  meet  with  failure.  An  attempt  should 
always  be  made  to  reduce  the  dislocation  by  abduction  and  trac- 
tion  up  in  the   upper  arm   and  pressure  with    the    hand    upon  the 


FRACTURES    OF    THE    UPPER    END    OF    THE    HUMERUS  1 43 

loose  head  in  the  axilla.  It  may  be  possible  to  reduce  the  dis- 
location in  this  manner.  If  this  method  fails,  an  attempt  should 
be  made  to  reduce  the  dislocated  head  by  open  incision  (arthrot- 
omy)  and  manipulation  of  the  upper  fragment  assisted  by  the 
McBurney- Porter  hook  manceuver.  If  this  attempt  is  successful, 
the  shaft  should  be  sutured,  with  an  absorbable  suture  or  fine 
silver  wire,  to  the  reduced  head,  and  the  shoulder  treated  as  if  a 
closed  fracture  existed. 

If  it  is  impossible  to  reduce  the  dislocated  head  or  if  the  head 
is  much  comminuted,  it  will  be  necessary  to  excise  it. 

If  operative  interference  has  been  decided  upon,  it  is  best  to 
defer  the  operation  until  the  acute  symptoms  have  subsided  and 
the  damaged  tissues  have  recovered  themselves:  It  is  the  result 
of  experience  that  operation  through  acutely  damaged  tissues  is 
unwise.  The  vitality  of  the  tissues  is  lessened  by  trauma,  hence 
the  resistance  to  infection  is  temporarily  impaired. 

If  the  reduced  head  of  the  humerus  becomes  necrosed  and 
abscesses  form  about  the  joint,  an  unusual  occurrence,  the  head 
of  the  bone  should  be  immediately  excised. 

The  After=treatment  of  Operated  Cases. — If  reduction  and 
suturing  have  been  accomplished,  passive  motion  should  not  be 
attempted  until  the  repair  at  the  seat  of  fracture  is  well  under 
way.  This  will  be  about  the  second  week.  Then  gentle  move- 
ment may  be  made  and  gradually  increased. 

If  resection  has  been  performed,  passive  motion  should  be 
gently  begun  almost  immediately — i.  e.,  within  the  first  forty- 
eight  hours — and  persistently  continued.  The  muscles  of  the 
shoulder  should  be  massaged  and  treated  by  electricity.  Abduc- 
tion should  not  be  attempted  to  any  great  extent  for  some  weeks 
after  the  operation  for  fear  of  displacing  the  upper  end  of  the 
humerus  too  far  from  the  glenoid  cavity.  The  final  results  fol- 
lowing reduction  and  suturing  have  been,  as  a  rule,  excellent, 
useful  arms  resulting  in  most  cases.  The  results  following  ex- 
cision are  only  fairly  satisfactory.  If  the  proper  amount  of  bone 
has  been  removed,  ankylosis  will  not  occur.  If  too  much  bone 
has  been  removed,  a  dangling  or  flail  joint  will  result.  An  ex- 
cision is  to  be  avoided  if  possible. 


H4 


FRACTURES    OF    THE    HUMERUS 


FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS 
Fracture  of  the  shaft  of  the  humerus  may  occur  at  any  point 
between  the  surgical  neck  and  the  condyles  (see  Fig.  171).  Its 
common  seat  is  at  the  middle  or  in  the  lower  third  of  the  bone 
(see  Fig.  172).  The  twisting  force  exercised  in  the  breaking  up 
of  adhesions  in  and  about  the  shoulder-joint  will  often  fracture 
a  humeral  shaft  obliquely.  The  strength  test  of  the  arms,  as 
seen  in  the  illustration,  has  been  the  cause  of  spiral  fracture  of 
the  humerus  (see  Figs.  173,  174). 


Shaft  of  hu- 
merus, up- 
per frag- 
ment. 


Fig.  171. — Fracture  of  shaft  of  humerus,  Fig.  172. — Fracture  of  the   shaft  of  the 

high.     Displacement  of  lower  end  of  upper        humerus   in   lower  third.     Displacement   of 
fragment  inward  (X-ray  tracing).  hoih  fragments  forward  (X-ray  tracing). 


Symptoms. — The  symptoms  are  readily  recognized.  They 
arc  swelling  at  the  seat  of  fracture,  pain,  crepitus,  abnormal 
motion,  and  ecchymoses.  Paralysis  of  the  musculospiral  nerve 
may  occur,  with  the  characteristic  wrist-drop.  Ordinarily,  the 
attention  of  both  the  patient  and  the  surgeon  is  so  occupied  with 
the  fracture  of  the  bone  and  its  associated  loss  of  movement  that 
h>ss  of  power  and  sensation,  because  of  involvement  of  the 
nerve,  go  unrecognized.  If  injury  to  the  musculospiral  nerve  is 
not   recognized  at  the   outset,  it   may  be  overlooked   until  the 


pig    i73—  Trial  of  strength  of  arms  resulting  sometimes  in  spiral  fracture  of  the  humerus 
(Monks).     See  figure  174. 


V 


Fig.  174.— Illustrating  spiral  fracture  of  humerus  (Monks).     See  figure  173. 


145 


I46  FRACTURES    OF    THE    HUMERUS 

splints  are  removed.  The  exact  duration  and  the  cause  of  the 
paralysis  can  not  then  be  readily  ascertained.  The  patient  may 
wrongly  attribute  the  paralysis  to  the  pressure  of  the  splints. 
Very  rarely,  injury  or  pressure  upon  the  large  vessels  of  the  arm 
is  met  with.  Damage  to  the  artery  will  be  suggested  by  weak 
or  absent  pulse  at  the  wrist  or  by  local  evidences  of  hemorrhage. 
A  swelling  appearing  suddenly,  greater  than  that  which  would 
appear  from  the  laceration  of  soft  tissues  alone,  should  suggest 
rupture  of  large  vessels.  Measurement  of  the  humerus  should 
be  made  from  the  edge  of  the  acromial  process  to  the  external 
condyle  of  the  humerus  (see  Fig.  143).  The  amount  of  overlap- 
ping of  the  fragments  will  be  shown  by  this  measurement. 

Treatment. — For  purposes  of  treatment,  fractures  of  the  shaft 
may  be  grouped  into  those  with  little  or  no  displacement  and 
those  with  considerable  displacement  and  difficult  of  retention 
after  reduction.  The  fracture  should  be  reduced  by  traction 
upon  the  condyles  of  the  humerus  and  countertraction  upon  the 
upper  arm  and  by  manipulation  of  the  fractured  bones. 

Treatment  of  Fractures  of  the  Shaft  of  the  Humerus  with 
Little  or  no  Displacement  (see  Figs.  175,  176). — The  fol- 
lowing materials  are  needed  for  the  apparatus  to  be  used  :  Ordi- 
nary dusting-powder, — which  is  powdered  oxid  of  zinc  and  pow- 
dered starch,  equal  parts  ;  a  bandage  of  Shaker  flannel  three 
inches  wide,  not  cut  on  the  bias  ;  an  axillary  pad  made  with 
several  layers  of  sheet  wadding  covered  with  a  folded  piece  of 
pasteboard,  and  the  whole  inclosed  in  cotton  cloth  stitched  at 
the  edges  ;  the  pad  is  V-shaped,  and  long  enough  to  extend  from 
the  apex  of  the  axilla  to  just  above  the  internal  condyle  of  the 
humerus  ;  it  is  broad  enough  to  support  the  upper  arm  comfort- 
ably and  securely  ;  the  lower  part  of  the  pad  is  about  three 
inches  thick  (see  Fig.  177),  so  as  to  support  the  arm  only  a 
trifle  abducted  from  the  side — that  is,  just  away  from  the  per- 
pendicular. If  the  axillary  pad  is  too  short,  there  is  danger  of 
causing  an  outward  bowing  of  the  humerus  (see  Fig.  179). 
Two  straps  are  attached  to  the  upper  corners  of  the  apex  of  the 
V-shaped  pad  long  enough  to  surround  the  body  and  go  over 
the  opposite  shoulder.  These  straps  hold  the  pad  in  position. 
The  remaining  apparatus  consists  of  two  or  three  thin  coapta- 


Fis 


175. — Fracture  of  the  shaft  of  the   humerus.      Note   bandage  to   hand,   forearm,  and 
elbow  ;  axillary  pad  and  strap  ;  coaptation  splints  and  sling. 


Fig.  176.— Fracture  of  the  shaft  ot  the  humerus.  Note  handage  to  hand,  forearm,  and 
elbow;  adhesive-plaster  swathe  holding  arm  upon  axillary  pad  and  covering  coaptation 
splints.     Sling. 

147 


148 


FRACTURES    OF    THE    HUMERUS 


tion  splints  for  application  to  the  upper  arm  ;  these  are  made 
quickly  by  laying  thin  splint  wood  upon  adhesive  plaster,  and 
splitting  the  wood  longitudinally  (see   Fig.    178);    three  adhe- 


Fig-  177- — Space  to  be  filled  by 
axillary  pad  between  arm  and  side 
in  fracture  of  bumerus. 


Fig.  178.  —  Coaptation 
splint  seen  flat  and  in  sec- 
tion. Made  by  laying  thin 
wood  on  adhesive  plaster 
and  splitting  with  knife. 


Fig.  179.— Showing  effect  (bowing  outward)  of  too  short  an  axillary  pad  upon  a  fracture  of  the 

shaft  of  the  humei  us. 


sive  straps  two  inches  wide  to  hold  the  coaptation  splints  ;  an 
adhesive  plaster  swathe  wide  enough  to  extend  from  the  acro- 
mion tip  to  the  external  condyle,  and  long  enough  to  surround 


TREATMENT    OF    FRACTURES    OF    THE    SHAFT  I49 

the  body  and  upper  arm  ;  a  cravat  sling  ;  a  thin  towel  or  piece 
of  compress  cloth  for  the  forearm  to  rest  upon.  All  these 
articles  should  be  in  readiness. 

Etherization  of  the  patient  will  rarely  be  necessary.  In  cases 
of  nervous  and  sensitive  women  and  unmanageable  young 
children  it  will  be  wise  to  use  an  anesthetic.  The  whole  upper 
extremity,  axilla,  and  chest  should  be  washed  with  soap  and 
water,  thoroughly  dried,  and  dusted  with  powder ;  then  the 
reduced  fracture  is  held  in  position  by  an  assistant  while  the 
apparatus    is    being    applied.       The    hand,  forearm,  and  elbow 


Fig.  180. — High  fracture  of  the  shaft  ot  the  humerus.     A  common  and  improper  use  of  an 
internal  right-angle  splint. 

should  be  snugly  and  evenly  covered  by  the  flannel  bandage  (see 
Fig.  165).  The  upper  arm  should  be  surrounded  by  the  coapta- 
tion splints,  held  in  place  by  the  three  straps  of  adhesive  plaster, 
so  as  to  secure  the  fractured  bone  perfectly  (see  Fig.  175).  The 
axillary  pad  should  be  placed  in  the  axilla  and  held  by  the  straps 
passed  over  the  opposite  shoulder  and  under  the  opposite  axilla. 
The  upper  arm  should  rest  comfortably  upon  the  pad.  To  prevent 
chafing,  the  thin  towel  or  compress  cloth  should  be  placed 
beneath  the  forearm  where  it  touches  the  body.  The  plaster 
swathe  should  then  be  applied  over  the  arm  to  the  body,  so  as  to 


15° 


FRACTURES    OF    THE    HUMERUS 


encircle  completely  the  trunk  (see  Fig.  176).  Thus  the  arm  is 
absolutely  fixed  to  the  axillary  pad  and  side.  The  wrist  should 
be  supported  in  a  cravat  sling  passed  around  the  neck.  The 
elbow  is  left  unsupported.  The  weight  of  the  upper  extremity 
will  thus  tend  to  exert  slight  downward  traction  upon  the  lower 
fragment  of  the  humerus.  Under  no  circumstances  should  an 
ordinary  broad  sling  be  used,  because  of  the  danger  of  making 
upward  pressure  upon  the  forearm  and  elbow  and  so  pushing  up 
the  lower  fragment  of  the  humerus.  The  elbow-joint  should 
not  be  immobilized  for  the  reason   that  it  would  then  be  much 

more  difficult  to  hold  the  seat 
of  fracture  fixed.  With  the 
elbow-joint  fixed,  the  lower 
arm  of  the  lever  is  greatly  in- 
creased, and  instead  of  move- 
ment of  the  forearm  taking 
place  at  the  elbow-joint  it 
would  take  place  at  the  seat 
of  fracture.  Fractures  of  the 
shaft  of  the  humerus  are 
frequently  treated  by  an  in- 
ternal angular  splint  and  co- 
aptation splints,  the  upper 
ends  of  the  splints  barely 
reaching  the  fracture,  or,  at 
best,  being  an  inch  or  two 
above  it  (see  Fig.  1 80).  When 
the  fracture  of  the  bone  is 
within  the  lower  third  of  the  shaft,  then  and  then  only  should 
an  internal  angular  splint  be  used  in  connection  with  coaptation 
splints. 

After-treatment. — The  patient  should  be  seen  each  day  for 
the  first  three  days  in  order  that  the  surgeon  may  be  informed  as 
to  the  exact  condition  of  the  parts.  There  may  be  undue  pres- 
sure. The  patient  maybe  uncomfortable.  The  splints  may  need 
readjusting.  Attention  to  little  details  of  discomfort  is  impor- 
tant. The  dressing  should  be  reapplied  with  great  care  once  each 
week.      The  parts  covered  by  splints  should  at  each  dressing  be 


Fig.  181. — View  of  right  humerus  from 
above,  showing  axes  of  upper  and  lower  ends. 
Head  of  bone  looks  in  the  same  general  direc- 
tion as  the  internal  condyle,  but  slightly  further 
backward.  These  relations  are  to  be  preserved 
when  treating  fractures  of  the  shaft  of  the 
humerus. 


TREATMENT  OF  FRACTURES  OF  THE  SHAFT        I  5  I 

carefully  inspected  to  detect  any  points  of  undue  pressure,  indi- 
cated by  reddening  of  the  skin.  If  these  are  discovered,  they 
should  be  washed  with  alcohol  and  covered  with  flexible  collo- 
dion or  a  drying  powder.  The  undue  pressure  should  be 
removed  by  shifting  the  padding.  Union  will  be  found  to  be 
firm  after  about  three  or  four  weeks.  As  soon  as  union  is  solid, 
— at  the  end  of  four  or  five  weeks, — the  swathe  may  be  omitted, 
the  coaptation  splints  alone  being  a  sufficient  support.  After 
about  five  weeks  or  five  weeks  and  a  half  all  support  may  be 
removed  from  the  arm.  The  arm  is  then  put  in  the  sleeve  of 
the  clothes,  and  the  wrist  supported  by  a  sling.  After  eight 
weeks  the  sling  may  be  discarded  and  moderate  careful  use  of 
the  limb  in  light  movements  be  indulged  in. 

Fracture  of  the  Shaft  of  the  Humerus  with  Considerable 
Displacement. — Obviously,  the  method  described  for  the  treat- 
ment of  fractures  without  great  displacement  will  be  of  compara- 
tively little  value.  Occasionally,  it  will  be  found  that  this  method 
will  hold  even  greatly  displaced  fractures  ;  it  should  then  be 
used.  The  ideally  perfect  method  for  such  cases  is  traction  and 
countertraction  upon  the  arm  with  the  patient  lying  on  the  back 
in  bed.  Coaptation  splints  should  be  used,  as  in  simple  uncom- 
plicated fractures.  '  If  all  methods  fail  to  hold  the  fragments 
reduced,  open  incision,  reduction  of  the  displacement,  and  sutur- 
ing of  the  fragments  are  indicated. 

The  plaster-of-Paris  splint,  applied  with  the  plaster  roller  to 
the  forearm  and  arm,  and  the  spica  bandage  to  the  shoulder  and 
chest  are  often  efficient  in  these  difficult  cases.  In  the  applica- 
tion of  this  splint  it  is  of  supreme  importance  that  an  assistant 
hold  the  arm  so  that  the  alinement  of  the  bones  remains  perfect. 
The  assistant  who  holds  the  arm  should  have  nothing  else  to  do. 
Before  applying  the  plaster-of-Paris  splint  it  is  often  advisable  to 
apply  thin  coaptation  splints  at  the  seat  of  fracture  to  give  addi- 
tional strength  to  the  splint.  With  these  coaptation  splints  in 
use  a  lighter  plaster  splint  may  be  applied  without  sacrificing 
strength.  A  narrow  cotton  swathe  about  the  body  and  arm 
should  steady  the  upper  extremity.  The  wrist  should  be  sup- 
ported by  a  cravat  sling. 

The  after-care  of  a  case  treated  by  the  plaster  splint  will  be 


152 


FRACTURES    OF    THE    HUMERUS 


similar  to  that  following  any  other  treatment  after  union  has 
occurred.  The  plaster  may  be  left  in  situ  for  four  weeks  ;  then, 
ordinarily,  repair  will  be  found  so  far  advanced  that  the  plaster 
splint  may  be  dispensed  with  and  the  ordinary  coaptation  splints 
and  swathe  may  be  used.  If  the  plaster  splint  has  proved  com- 
fortable, it  may  be  split  and  reapplied. 

Massage  and   Passive   Motion  :   In  view  of  the  possibility  of 


Fig.  182.— Case:  Fracture  of  tlie  shalt  of  the  left  humerus.     Fracture  united.     Note  atrophy 
of  upper  arm,  including  deltoid.     Loss  of  muscular  contour  very  apparent. 


nonunion  of  this  fracture,  it  will  be  wise  not  to  begin  massage 
until  union  has  begun.  Passive  motion  to  the  shoulder  and 
elbow  should  be  gently  made  at  as  early  a  date  as  possible,  with 
due  consideration  to  the  condition  of  repair  in  the  fracture.  If 
at  the  end  of  three  weeks  union  is  found  to  have  begun,  it  will 
be  wise  to  move  the  shoulder  and  elbow  gently  by  passive 
motion.  The  seat  of  fracture  should  be  cautiously  guarded 
against  movement  during  these  gentle   manipulations.      A  little 


MUSCULOSPIRAL    NERVE    INVOLVEMENT  I  53 

gentle  passive  movement  of  this  sort  repeated  occasionally  dur- 
ing the  process  of  repair  will  assist  very  considerably  in  the 
restoration  of  the  functional  usefulness  of  the  shoulder  and  elbow, 
which  so  often  become  stiff  from  immobilization. 

Prognosis. — Ordinarily,  union  occurs  readily  in  from  four  to 
six  weeks.  In  childhood  union  is  quite  solid  in  from  three  to 
five  weeks.  Fractures  of  this  bone  are  more  likely  to  be  followed 
by  nonunion  than  fracture  of  any  other  bone  in  the  body.  The 
presence  of  abnormal  mobility  after  a  considerable  time  (three 
months)  has  elapsed  is  the  sign  of  nonunion  by  bone.  Consider- 
able muscular  atrophy  follows  this  fracture  (see  Fig.  182).  Upon 
using  the  arm  again  and  by  massage  the  size  of  the  arm  is,  in  a 
great  measure,  restored.  The  stiffness  of  the  shoulder  and  elbow 
which  is  sometimes  associated  with  this  injury  is  due  to  long  im- 
mobilization without  passive  motion. 

Fracture  of  the  shaft  of  the  humerus  sometimes  occurs  in 
the  new=born  during  delivery  or  afterward.  The  arm  is  best 
immobilized  by  thin  coaptation  splints.  These  splints  may  be  as 
thin  as  six  thicknesses  of  ordinary  letter  paper,  and  may  be  made 
of  cardboard.  The  humerus  is  completely  surrounded  by  them. 
They  are  held  firmly  by  adhesive-plaster  straps.  If  they  are  cut 
the  right  length  and  width,  they  may  be  applied  most  efficiently 
without  padding.  A  liberal  amount  of  drying  powder  should  be 
rubbed  on  the  arm  and  chest.  A  piece  of  compress  cloth  should 
be  placed  on  the  side  of  the  chest  under  the  injured  arm,  to  pre- 
vent chafing.  The  upper  arm  is  then  held  to  the  side  of  the 
chest  by  a  gauze  or  other  cloth  swathe.  Repair  is  rapid.  Union 
is  firm  in  about  three  weeks.  Fracture  of  the  humerus  in  the 
new-born  is  sometimes  associated  with  obstetrical  paralysis  of  the 
upper  extremity.  This  obstetrical  paralysis  should  not  be  con- 
founded with  musculospiral  paralysis. 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus. — 
The  musculospiral  nerve  may  be  involved  in  fracture  of  the 
humeral  shaft,  particularly  if  the  fracture  is  at  the  middle  or  in 
the  lower  third  of  the  bone.  The  nerve  lies  in  the  musculo- 
spiral groove  of  the  humerus.  It  leaves  the  bone  a  little  below 
the  junction  of  the  middle  and  lower  thirds  of  the  arm  (see  Fig. 
183).      The  nerve  may  be  involved  primarily  at  the  time  of  the 


154 


FRACTURES    OF    THE    HUMERUS 


accident  by  the  contusion  or  laceration  caused  by  the  original 
violence  or  by  the  pressure  of  bony  fragments.  The  nerve  may 
also  be  involved  secondarily  by  the  pressure  of  the  bony  callus 
or  of  the  cicatricial  tissue  of  the  soft  parts. 

Symptoms. — Contusion  of  the  musculospiral  nerve  may  be 
slight  or  severe.  If  slight,  there  will  be  pain  at  the  injured  place, 
and  a  tingling  and  numbness  along  the  distribution  of  the  nerve. 
These  symptoms  may  pass  away  quickly  or  the  tingling  may 
remain  several  days.  If  it  remains,  a  chronic  neuritis  is  estab- 
lished associated  with  shooting  and  neuralgic  pains.  If  the 
contusion  is  severe,  there  will  be  complete  anesthesia  and  com- 
plete paralysis  of  the  nerve  below  the  place  involved.  This  may 
pass  away  early  or  it  may  remain  several  months  or  it  may  be- 


Fig.  183.— Relations  of  musculospiral  nerve  on  outer  side  of  arm  (from  dissected  speci- 
men) :  a,  Clavicle  ;  b,  deltoid  ;  c,  pectoralis  major  ;  d,  biceps  ;  e,  brachialis  anticus  ;  /,  triceps  ; 
g,  musculospiral  nerve. 


come  permanent.  Pressure  upon  the  nerve  from  callus,  cicatri- 
cial tissue,  and  bony  fragments  will  give  signs  of  disturbed  sen- 
sation and  motion  in  the  parts  supplied  by  the  nerve. 

Compression  of  the  Musculospiral  Nerve  :  The  musculospiral 
nerve  supplies  the  triceps,  brachialis  anticus,  supinator  longus, 
and  extensor  carpi  radialis  longior  muscles.  Inability  to  extend 
the  fingers  and  wrist  and  loss  of  supination  are  the  usual  signs 
of  motor  paralysis  following  compression  of  this  nerve.  As  for 
sensation,  there  will  be  complete  loss  or  impaired  sensation  in 
the  lower  half  of  the  outer  and  anterior  aspect  of  the  arm  and  in 
the  middle  of  the  back  of  the  forearm  as  far  as  the  wrist. 

Treatment. — Immediate  paralysis  does  not  necessarily  mean 
pressure  by  a  bony  fragment.      Such  paralysis  may  be  associated 


FRACTURES    OF    THE    ELBOW 


155 


with  contusion  ;  therefore,  operative  interference  should  be 
delayed.  If  the  symptoms  persist  for  four  or  five  months,  ex- 
posure of  the  nerve  and  relieving,  if  possible,  the  conditions 
found  are  indicated.  It  is  wise  to  allow  the  fractured  bone  to 
unite  before  operating. 

The  prognosis  after  the  removal  of  pressure  and  following 
resection  and  suture  of  the  musculospiral  nerve  is  good  as  to 
the  ultimate  partial  or  complete  recovery.  After  a  few  days  or 
weeks  sensation  will  return.  After  a  few  months — five  to  eight 
— motion  will  begin  to  return  (see  Figs.  184,  185,  186). 


Fig.  184. — Double  fracture  of  humeral  shaft.  Immediate  musculospiral  paralysis.  Union 
of  bones  in  six  weeks.  Operation  to  free  nerve  from  lower  fragment.  Sensation  and  motion 
returned.    Same  case  as  figure  185. 


Malignant  Disease. — Carcinoma  is  said  to  have  occurred  sec- 
ondarily in  a  fractured  bone.  Sarcoma  develops  in  the  callus  of 
fractures.  It  is  highly  probable  that  in  many  of  the  so-called 
sarcomata  of  callus  the  disease  preexisted  in  the  bone,  and  was 
the  reason  for  the  fracture  occurring  after  trivial  injury. 


FRACTURES  OF  THE  ELBOW 
Fractures  of  the  lower  end  of  the  humerus  near  to  and  involving 
the  elbow-joint  are  frequent  in  childhood,  but  much  less  frequent 
in  adults.  A  familiarity  with  the  bony  landmarks  of  the  elbow 
is  essential  to  an  accurate  diagnosis.  The  more  nearly  accurate 
the  diagnosis,  the  more  efficient  will  be  the  treatment  and  the 


-r 


P    Loose  fragment  of 
shaft. 


_  Condyle  of  humerus. 


Fig.  1S5. — Same  as  figure  1S6.     Lateral  view  to  show  displacement  of  fragment 
(X-ray  tracing). 


1 —  Upper  fragment  of 

humerus 


—  Middle  loose  fragment. 


Lower  fragment. 


Fig.  186.— Double  fracture  of  the  humerus.  Paralysis  of  the  musculospiral  nerve.  Im- 
mediate union  of  bone.  Suture  of  nerve  found  caught  between  fragments.  Gradual  recovery. 
Same  as  figure  1S5  (  X-rav  tra<_:i 

156 


EXAMINATION    OF    THE    ELBOW 


157 


more  intelligent  will  be  the  prognosis.  Every  elbow  injury,  no 
matter  how  trivial,  should  be  examined  under  anesthesia. 

Method  of  Examination. — The  normal  anatomical  relations 
of  the  uninjured  elbow  are  to  be  first  determined.  The  large 
prominent  internal  condyle  of  the  humerus,  the  olecranon  pro- 
cess of  the  ulna,  the  external  condyle,  the  head  of  the  radius  are 
each  in  turn  to  be  grasped  by  the  thumb  and  forefinger.  If 
these  bony  points  can  be  recognized  upon  the  injured  elbow, 
then  a  fracture  ought  not  to  be  overlooked. 

The  Three  Bony  Points  of  the  Elbow  Region  :  With  a  pencil 
or  ink  the  internal  and  external   condyles  of  the  humerus  and 


Fig.  187. — The  relations  of  the  three  bony  points  at  the  elbow  in  extension  and  in  flexion 
(from  behind).  The  marks  are  placed  upon  the  internal  and  external  condyles  and  olecranon 
process  (diagram). 


the  tip  of  the  olecranon  should  be  marked,  the  forearm  being 
extended.  Normally,  these  three  points  will  be  found  to  be  in 
nearly  a  straight  line  transverse  to  the  long  axis  of  the  limb.  The 
tip  of  the  olecranon  is  a  trifle  above  this  line  (see  Figs.  187,  188). 
Palpation  of  the  Three  Bony  Points  :  Grasping  the  left  wrist 
with  the  left  hand,  place  the  right  thumb  upon  the  external  con- 
dyle, the  third  finger  on  the  internal  condyle,  and  the  forefinger 
on  the  olecranon.  When  the  elbow  is  at  a  right  angle,  these 
three  points  will  be  found  in  the  same  plane  with  the  back  of  the 
upper  arm.  A  similar  examination  may  be  made  of  the  right 
elbow,  changing  hands  for  convenience  (see  Figs.  187,  189). 


-Normal  elbow.     Relation  of  the  three  bony  points  in  almost  complete  extension  of 
forearm.     Prominence  of  olecranon  and  two  condyles  evident. 


Normal  elbow.    Examination.    The  three  bonj  points 
thumb  and  two  lingers. 

I58 


Note  position  of  the 


EXAMINATION    OF    THE    ELBOW 


159 


The  Head  of  the  Radius  (see  Fig.  192)  :  Grasping  the  elbow 
with  one  hand,  the  thumb  resting  one-half  an  inch  below  the 
external  condyle  upon  the  head  of  the  radius,  and  holding  the 
wrist  in  the  other  hand,  the  patient's  forearm  is  pronated  and 
supinated.  If  the  shaft  of  the  radius  is  unbroken,  the  head  of 
the  radius  will  be  felt  to  move  under  the  thumb. 

The  Carrying  Angle  (see  Figs.  190,  191):  The  lateral  angle 


Fig.  190. — Normal  elbows.     Well-marked  carrying  angle  apparent. 


that  the  supinated  forearm  makes  with  the  upper  arm  is  called 
the  carrying  angle.  It  is  important  to  remember  that  this  angle 
varies  normally  within  very  wide  limits.  Some  individuals  have 
no  carrying  angle.  Its  presence  or  absence  is  of  little  functional 
value. 

Movements  at  the  Elbow-joint :  The  movements  of  the  joint 
should  be  determined  both  in  flexion  and  extension.  There  is 
normally  no  lateral  motion  in  the  extended  elbow-joint.    Abnor- 


i6o 


FRACTURES    OF    THE    HUMERUS 


mal  lateral  motion   in   cither  adduction   or  abduction  should  be 
detected  if  present. 

Measurements :     The     distance    between    the    two    condyles 
should  be   measured  on  the  uninjured  arm.      The  distance  from 


Fig.  191. — Position  of  supination,  showing  the  carrying  angle,     The  outline  shows  the 
position  of  pronation  with  disappearance.of  the  carrying  angle. 


the  acromial  process  to  the  external   condyle  of  the   humerus 
should  also  be  measured  (see  Fig.   143). 

Having  then  established  a  standard  of  comparison  in  the 
normal  elbow,  the  injured  elbow  should  be  examined  with  the 
greatest  care.      Even  when  there  is  great  swelling  of  the  elbow 


EXAMINATION    OF    THE    ELBOW 


161 


region,  steady  pressure  will  enable  the  fingers  to  reach  the  con- 
dyles. In  approaching  an  injury  to  the  elbow  the  questions 
which  arise  are  :  Is  there  a  dislocation  ?  Is  there  a  fracture  ? 
Are  both  dislocation  and  fracture  present  ?  Is  there  a  con- 
tusion and  a  sprain  ?  Is  there  a  subluxation  of  the  radial 
head?  In  the  absence  of  positive  signs  of  dislocation,  subluxa- 
tion, and  fracture  the  lesion  is  a  sprain   or   contusion.      In  the 


Fig.  192. — Normal  elbow.     Method  of  examination.     Palpating  head  of  radius.     Spot  marks 

external  condyle. 


absence  of  positive  signs  of  dislocation  and  radial  subluxation  a 
fracture  will  be  present. 

Summary  of  the  Order  of  Examination  of  the  Injured 
Elbow. — Notice  whether  the  swelling  and  ecchymosis  are  general 
or  localized.  If  localized,  that  may  determine  the  seat  of  the 
lesion.  Observe  the  carrying  angle.  Palpate  the  external  and  in- 
ternal condyles  (see  Fig.  193),  the  olecranon  process  of  the  ulna 
(see  Fig.  194), and  the  head  of  the  radius  (see  Fig.  192).  Determine 
if  crepitus  is  present.    See  if  the  head  of  the  radius  rotates.    Note 


Fig.  193. — Normal  elbow.     Method  of  examination.     Grasping  the  two  condyles  of  the 

humerus. 


Fig.  194.— Normal  elbow.     Method  of  examination.    Palpating  olecranon. 

162 


EXAMINATION'    OF    THE    INJURED    ELBOW 


163 


the  relations  of  the  three  bony  points,  with  the  forearm  flexed  at 
a  right  angle  and  completely  extended  (see  Figs.  187,  188,  189). 
Note  any  lateral  motion  at  the  elbow-joint  (see  Fig.  195).  Deter- 
mine the  possible  movements  of  the  elbow-joint.  Make  measure- 
ments. 

The  traumatic  lesions  of  the  elbow  may  be  grouped,  for  sim- 
plicity and  ease  of  reference,  in  the  following  manner.  During 
the  routine  examination  it  is  wise  to  have  in  mind  these  possible 
individual  lesions  : 

Lesions  of  the  Radius  and  Ulna  :  (a)  Dislocation  of  the  radius 


Fig.  195.— Normal  elbow.     Line  between  the  condyles.     Method  of  examining  for  supracon- 

dyloid  fracture. 


and  ulna  backward  with  or  without  fracture  of  the  coronoid  pro- 
cess of  the  ulna. 

(b)  Subluxation  of  the  radial  head. 

(  c)  Fracture  of  the  olecranon  process  of  the  ulna. 

(d)  Fracture  of  the  neck  or  head  of  the  radius. 

Lesions  of  the  Lower  End  of  the  Humerus  :  (t)  Fracture  of 
the  internal  epicondyle  (see  Fig.  196,  c,  c). 

{/)   Fracture  of  the  internal  condyle  (see  Fig.   196,  /;,  />). 


164 


FRACTURES    OF    THE    HUMERUS 


(<£")   Fracture  of  the  external  condyle  (see  Fig.  196,  d,  d). 

(//)  Transverse  fracture  of  the  shaft  of  the  humerus  above 
the  condyles  (supracondylar)  (see  Fig.  197,  a,  <?). 

(/')    Separation  of  the  lower  epiphysis  of  the  humerus. 

(/•)  T-fracture  into  the  elbow-joint  (see  196,  a,  a,  a,  and  Fig. 
197,  b,  b,  b). 

Symptoms  of  Lesions  About  the  Elbow=joint  with  the 
Differential  Diagnosis  of  Each  Lesion. — (rf)  A  Dislocation  of 
the  Radius  and  Ulna  Backward  with  or  without  Fracture  of  the 
Coronoid  Process  of  the  Ulna  :  There  may  be  very  great  swelling 
of  the  region  of  the  elbow.  The  relations  between  the  three  bony 
points  are  disturbed.      The  olecranon  process  is  very  prominent 


Fig.  196. — T-fracture,  high  (a,  </,  a). 
Fracture  of  internal  condyle  (b,  b).  Frac- 
ture of  internal  epicondyle  (c,  c).  Fracture 
of  external  condyle  (<i,  d)  (diagram). 


Fig.    197. — Supracoudyloid    fracture    (a,  a). 
T-fracture  low  down  (b,  b,  b)  (diagram). 


posteriorly.  The  radial  head  is  displaced  backward.  The  two 
condyles  are  far  in  front  of  the  olecranon.  There  is  abnormal 
Literal  mobility.  The  normal  movements  of  the  joint  are  re- 
stricted. This  injury  may  be  mistaken  for  a  supracondylar 
fracture.  The  important  difference  has  been  mentioned.  A  dis- 
location of  both  bones  backward,  if  reduced,  does  not  ordinarily 
tend  again  to  become  displaced  ;  if  it  does,  there  is  most  likely 
a  fracture  of  the  coronoid  process  of  the  ulna. 

(/;)  Subluxation  of  the  Head  of  the  Radius  :  This  takes  place 
in  children  under  five  years  of  age.  It  is  due  to  sudden  traction 
upon  the  extended  forearm,  which  so  often  occurs  in  lifting  a  child 


DIAGNOSIS    OF    ELBOW-JOINT    LESIONS 


I65 


by  the  arm  over  a  curbstone.  The  child  presents  the  arm  hang- 
ing slightly  away  from  the  side,  with  the  elbow  a  little  flexed 
and  the  hand  semipronated.  Attempts  to  use  the  arm  cause- 
pain.  The  extremes  of  flexion  and  extension  and  supination  are 
painful.  Inspection  will  detect  a  slight  swelling  one-half  of  an 
inch  to  an  inch  below  the  external  condyle  of  the  humerus.  Ten- 
derness is  present  over  the  head  of  the  radius.      The  relation  of 


Fig.  19S. — Fracture  of  the  internal  condyle.     Recovery  with  "  gunslock  "  deformity,  due  to 
slipping  upward  of  fragment  and  adduction  of  forearm. 


the  three  bony  prominences  is  preserved.  The  details  of  this  not 
uncommon  lesion  are  mentioned  because  it  is  sometimes  mistaken 
for  a  fracture  of  the  radial  head  or  a  simple  sprain  of  the  elbow. 
A  fracture  of  the  radius  below  the  neck  has  also  been  mistaken 
for  this  subluxation  of  the  head.  Careful  detailed  examination 
will  alone  clear  up  any  doubts. 


1 66 


FRACTURES    OF    THE    HUMERUS 


(c)  Fracture  of  the  Olecranon  Process  :  The  details  of  this  frac- 
ture are  considered  elsewhere.  Crepitus  and  mobility  of  the  olec- 
ranon fragment  will  be  felt.    There  may  or  may  not  be  separation 


Capitellum. ' 1- 

I 
Radius. J_ 


-^ Internal  condyle. 


Fig.  199. — Normal  right  arm  of  patient  in  figure  19S  (X-ray  tracing). 


Internal  condyle. 


• External  condyle. 

y— Capitellum. 

P.adius. 


Fig.  2fo. — Fracture  of  internal  condyle  of  left  humerus.      Recovery  with  deformity.     See 
figure  198  (X-ray  tracing). 

of  the  fragments.      If  there  is  a  separation,  it  will  be  detected  and 

the  three  bony  points  will  have  their  normal  relations  disturbed. 

{d)   Fracture  of  the  Neck  or  Head  of  the  Radius  :  This  is  un- 


DIAGNOSIS    OF    KLBOW-JOINT    LESIONS 


167 


common.  Swelling  over  the  radial  head  and  neck  is  present. 
Supination  and  pronation  are  painful  and  limited  and  attended 
by  crepitus,  muscular  spasm,  and  possibly  a  loss  of  rotation  of 
the  radial  head. 

(v)  Fracture  of  the  Internal  Epicondyle  :  The  epiphysis  of  this 
epicondyle  unites  to  the  shaft  of  the  humerus  between  the  eigh- 
teenth and  twentieth  years.  This  fracture  is  quite  common 
among  little  children.  If  this  fracture  presents  a  small  fragment, 
it  is  of  little  consequence.  If  a  large  fragment  is  broken  off,  it  is 
of  consequence.     The  displacement  is  downward  and  forward. 


Fig.  201. — Rachitis,  showing  adduction  of  forearm,  as  in  figure  15 


The  ulnar  nerve  is  sometimes,  though  rarely,  implicated  in  this 
injury. 

(/)  Fracture  of  the  Internal  Condyle  :  Swelling  over  this  con- 
dyle is  marked.  By  grasping  the  condyle  abnormal  mobility  and 
crepitus  are  detected  between  the  fragment  and  the  shaft.  The 
inner  of  the  three  bony  points  is  displaced  upward.  Lateral 
mobility  of  the  elbow  is  present ;  adduction  is  especially  free. 
The  carrying  angle  will  be  diminished  if  there  is  displacement  of 
the  condyle  upward  (see  Figs.  198,  199,  200). 


1 68 


FRACTURES    OF    THE    HUMERUS 


(£")  Fracture  of  the  External  Condyle  (see  Fig.  202) :  Swell- 
ing over  this  condyle  is  marked.  Crepitus  and  abnormal  mobility 
are  present.  The  normal  relations  of  the  three  bony  points  are 
disturbed.  The  external  condyle  is  displaced  upward.  The 
relation  of  the  external  condyle  and  the  head  of  the  radius  is 
undisturbed.  Lateral  motion  at  the  elbow  is  or  is  not  present. 
The  transverse  measurement  of  the  elbow  is  greatest  on  the 
injured  side.      Supination  will  be  somewhat  limited. 

(//)  Transverse  Fracture  of  the  Shaft  of  the  Humerus  Above 
the  Condyles.  Supracondyloid  Fracture  (see  Fig.  203)  :  The  line 
of  this  fracture  is  higher  up  on  the  shaft  than  the  line  of  the 


\ 

<^A 1 External  condyle. 

I  — \ —  i Capitellum. 

-  J Upper  radial  epiphysis. 


Fig.  202. — Fracture  of  external  condyle  of  humerus.     Child  five  years  of  age.     Nucleus  for 
capitellum  seen  below  fragment. 


epiphysis.  A  fullness  will  be  noticed  in  front  of  the  elbow- 
joint,  and  posteriorly  the  point  of  the  elbow  will  appear  prom- 
inent. The  small  lower  fragment  is  displaced  backward  with  the 
bones  of  the  forearm;  the  upper  fragment  or  shaft  of  the 
humerus  is  displaced  forward,  causing  the  fullness  in  the  bend  of 
the  elbow  (see  Fig.  205).  The  three  bony  points  maintain  their 
normal  relations.  This  distinguishes  the  fracture  from  a  disloca- 
tion of  both  bones  backward  (see  Fig.  206).  Crepitus  will  be 
detected  upon  grasping  the  arm  firmly  above  and  below  the 
dhow  -joint  (see  I*'ig.  1 95).  Recurrence  of  the  displacement  often 
follows  its  correction  unless  the  fracture  is  properly  immobilized. 


Fig.  203. — Case  of  transverse  fracture  above  the  condyles  of  the  left  humerus;  characteristic 
deformity.     The  anterior  deformity  is  higher  than  in  a  case  of  dislocation  of  the  elbow. 


Fig.  204. — Transverse  fracture  above  the  condyles  of  the  humerus.     Same  as  figure  203. 

1(9 


Fig.  205,-Siipracondyloid  fracture  of  humerus.     Elbow  flexed  to  a  right  angle.     Diagram  to 
show  displacement  of  hones. 


V;,;'",' "ofJ?°thb°»«  of  the  forearm  backward.     Elbow  flexed  to  right  ancle 

Diagram  sh,  wing  relative  position  of  bones.    Compare  with  figure  205.  ' 


170 


I  il  INFERENTIAL    DIAGNOSIS 


171 


Abnormal  lateral  and  anteroposterior  mobility  above  the  elbow- 
joint  is  found  (see  Figs.  203,  204). 


Humeral  shaft . 


. Epiphysis. 

Capitellum. 


pjo-    207 —Displacement  of    lower  epiphysis  of  humerus  backward,  with   fracture  of  the 
diaphysis.     Child  seven  years  of  age  (X-ray  tracing). 


Shaft  of  humerus.  - 
Capitellum.  -- 


Radius. 


enosteum. 

ower  epiphysis  of 
humerus. 

[  Ulna  shaft. 


Fig.  208.— Separation  of  the  lower  epiphysis  of  the  humerus  and  displacement  of  the  fore- 
arm inward.  Boy  nine  years  of  age.  See  figure  209  (X-ray  tracing)  (Massachusetts  General 
Hospital,  1502). 

(/)  Separation  of  the  Lower  Epiphysis  of  the  Humerus  :  The 
lower  epiphysis  of  the  humerus   unites  to  the  shaft  about  the 


i;2 


FRACTURES    OF    THE    HUMERUS 


seventeenth  year.      It  includes  only  the  very  lowest  end  of  the 
humerus.      The   lower  epiphysis  of  the  humerus  is  made  up  of 


Epiphysis. 1- 


Capitellum. 


Radius. ^ 


Epiphysis. 

Shaft  of  humerus. 

Ulna. 


Fig.  209. — Lateral  view  of  figure  208,  showing  forward  displacement  of  the  shell  of  the 
epiphysis  and  the  lateral  displacement  of  the  ulna  (X-ray  tracing)  (Massachusetts  General 
Hospital,  1502). 


Capitellum. 


Fig.  210.— Same  as  figure  208,  after  reduction.    Lateral  view.    Internal   right-angle  splint 
seen  in  position  (X-ray  tracing). 

the  external  epicondyle,  the  capitellum,  and  the  trochlea.  These 
separate  centers  of  ossification  unite  about  the  thirteenth  year, 
and  at  about  the  seventeenth  year  they  join  the  shaft  of  the  bone. 


DIFFERENTIAL    DIAGNOSIS 


173 


The  epiphysis  of  the  internal  epicondyle  is  entirely  separate  from 
the  large,  general,  lower,  humeral  epiphysis. 


Shalt  of  humerus. 


Epiphysis. 


Fig.  211.— Separation  of  the  lower  humeral  epiphysis  (X-ray  tracing)  (Massachusetts  General 

Hospital,  742). 


/ 

/ 

.,.J r Shaft  of  humerus. 

iVyttfffD J. Lower  humeral  epiphysis  and 

\\^W\/\S^           /  bits  from  the  diaphysis. 
/ Capitellum. 

/ 
/ 
/ 


Fig-.  212. — Separation  of  the  lower  humeral  epiphysis.  Child  nine  years  of  age.  Separa- 
tion reduced.  Capitellum  and  epiphysis  distinctly  seen  in  the  lateral  view.  Internal  angular 
tin  splint  shown. 

This  is  a  not  uncommon  accident.  It  occurs  usually  in  chil- 
dren under  ten  years  old.  There  is  no  change  in  the  relations 
of  the  three  bony  points.       It  somewhat   resembles   transverse 


174 


FRACTURES    OF    THE    HUMERUS 


fracture  above  the  condyles.  The  diagnosis  is  made  upon  the 
following  points  :  The  age  of  the  individual  ;  the  history  of 
the  accident ;  the  existence  of  abnormal  mobility  at  a  very  low 
level    on    the    humeral    shaft ;     anteroposterior    mobility    very 


Olecranon  fossa. 


Interna]  portion  of 
epiphysis. 


Ulna.  —  -—  __ 


Humeral  epiphysis  and 
— .      bits  from  the  diaphy- 
sis. 

—  -  Capitellnm. 

—  -  Radial  epiphysis. 

—  Radius. 


Fig.  213.— Separation  of  the  lower  epiphysis  of  the  humerus,  after  union.  Anteropos- 
terior view.  This  figure  illustrates  the  fact  that  the  epiphysis  does  not  include  the  condyles 
of  the  humerus  (X-ray  tracing). 


Z3fcf+- 


United  humeral 
epiphysis. 

Capitellnm. 


1 

1 
Radial  epiphysis. 

Fig.  214. — Separation  of  the  lower  humeral  epiphysis,  after  union.     Lateral  view.     Extension 
normal.     Flexion  to  a  right  angle  (X-ray  tracing)  (Massachusetts  General  Hospital,  1556). 


marked,  lateral  mobility  being  less  marked  ;  muffled  crepitus 
(this  term  is  very  suggestive,  and  is  used  by  Poland).  The 
breadth  of  the  lower  end  of  the  humeral  fragment  is  broader 
than   in   the   case  of  a  fracture  (see  Figs.  207  to  214  inclusive). 


DIFFERENTIAL    DIAGNOSIS  1J5 

(k)  T-fracture  into  the  Elbow-joint  (sec  Figs.  215,  216,  217;: 
The  traumatism  which  causes  this  injury  may  be  extremely  slight. 
If  the  two  condyles  are  grasped,  crepitus  and  abnormal  mobility 
will  be  detected.  The  relations  of  the  three  bony  points  will 
be  disturbed,  according  as  one  or  both  condyles  are  displaced. 
The  transverse  measurement  of  the  condyles  will  be  found  to  be 
increased.  There  will  be  abnormal  lateral  mobility,  both  in 
adduction  and  abduction. 

A  systematic  anatomical  examination  of  injuries  to  the  elbow 


Fig.  215.  —  Compound 
fracture  of  elbow — T-frac- 
ture— following  epiphyseal 
lines  in  part.  Boy  of  about 
nine  years  of  age.  Forearm 
also  extensively  injured. 
Amputation. 


Fig.  216. — T-fracture  of 
elbow.  Man  of  forty-five, 
fell  twenty  feet  and  struck 
elbow,  producing  com- 
pound fracture.  Arm  am- 
putated (Warren  Museum, 
specimen  999). 


Fig.  217. — T-fracture  of 
humerus,  low  down.  Man 
of  forty-eight,  fell  down- 
stairs. Arm  amputated 
(Warren  Museum,  speci- 
men 1102). 


under  an  anesthetic  will  overcome  much  of  the  indenniteness  that 
surrounds  these  injuries.  A  crushed  elbow,  feeling  to  the  ex- 
amining hand  like  a  bag  of  bones,  can  not  always  be  accurately 
diagnosed,  some  of  the  details  of  the  lesions  naturally  remaining 
undetermined.  The  Rontgen  ray  in  these  doubtful  cases  will  be 
of  material  assistance.  The  importance,  however,  of  making  such 
a  careful  eliminative  examination  as  is  described,  both  from  the 
point  of  view  of  treatment  and  prognosis,  can  not  be  overesti- 
mated. 


176 


FRACTURES    OF    THE    HUMERUS 


Treatment. — The  object  of  treatment  is  to  restore  the  elbow- 
joint  to  its  normal  condition.  If  the  fracture  is  attended  by 
great  swelling,  it  will  be  necessary  to  temporarily  support 
the  arm  until  the  swelling  reaches  its  maximum  and  begins  to 
subside.  The  right-angle  internal  angular  splint  is  the  most 
satisfactory  for  this  purpose  (see  Figs.  218,  219).  The  maxi- 
mum swelling  will  have  taken  place  after  forty-eight  to  seventy- 


Fig.  218.— Method  of  manufacture  of  tin  internal  right-angle  splint  :  a,  Form  into  which 
piece  of  tin  is  folded  (with  vise  and  hammer);  b  shows  the  bend  in  the  back  ridge  completed 
bent  with  pliers,  hammered  close  in  the  vise);  c,  the  completed  splint  with  edges  shaped  and 
covered  with  adhesive  plaster,  and  with  the  surfaces  of  the  splint  properlv  concaved. 


Fig.  219.— Patterns  of  pieces  used  in  making  the  usual  (soldered)  internal  right-angle  splint, 
seen  applied  in  figure  228. 

two  hours.  This  temporary  dressing  will  rarely  be  needed.  In 
general,  it  may  be  stated  that  the  arm  should  be  placed  in  that 
position  in  which  it  is  found,  upon  experiment  with  the  fracture 
under  consideration,  that  the  fragments  are  best  held  reduced. 

Fractures  of  the  internal  epicondyle,  of  the  internal  condyle,  of 
the  external  condyle,  and  T-fraetnres  into  the  joint  are  best 
treated,  as  a  rule,  in  the  acutely  flexed  position. 


TREATMENT    OF    FRACTURES    OF    THE    ELBOW 


// 


Experimental  evidence,  both  upon  the  cadaver  and  on  the 
anesthetized  living  subject,  confirmed  by  clinical  experience 
extending  over  a  number  of  years  in  the  hospital  and  private 
practice  of  many  different  surgeons,  demonstrates  that  the  acutely 
flexed  position  actively  reduces  and  holds  reduced  the  fractures 
previously  mentioned.  In  the  acutely  flexed  position  the  cor- 
onoid  process  in  front,  the  trochlear  surface  of  the  olecranon 
behind,  and  the  fasciae  posteriorly  and  laterally,  together  with  the 


Fig.  220. — Supracondyloid  fracture  of  the  humerus.  Method  of  reduction  before  applying 
retentive  splint.  Countertraction  on  upper  arm.  Traction  on  condyles  of  humerus  with 
right  hand;  backward  pressure  with  thumb  of  left  hand.  Also  illustrative  of  method  of 
beginning  acute  flexion. 


tendon  of  the  triceps  posteriorly,   hold  the  fragments  reduced 
and  close  to  the  shaft  of  the  humerus. 

Method  of  Using  the  Acutely  Flexed  Position  :  The  condyles 
of  the  humerus  are  grasped  by  the  thumb  and  finger  of  one  hand, 
a  finger  of  the  other  hand  is  placed  in  the  bend  of  the  elbow,  trac- 
tion is  made  upon  the  forearm,  and  it  is  slowly  flexed  to  an  acute 
angle.  While  the  forearm  is  being  flexed,  traction  and  lateral 
pressure  are  brought  to  bear  upon  the  loose  fragments  of  the 
humerus  to  correct  existing  malpositions.  These  manipulations 
will  materially  assist  in  the  reduction  (see  Fig.  220). 

The  degree  of  flexion  will  be  determined  by  the  obstruction 
12 


i  ;8 


FRACTURES    OF    THE    HUMERUS 


offered  by  the  local  swelling.  If  the  swelling  is  great,  or  is  likely 
to  increase  very  much,  then  the  degree  of  flexion  must  be  less 
than  when  there  is  no  swelling.  In  the  bend  of  the  elbow,  to  pre- 
vent chafing,  is  placed  a  piece  of  gauze  upon  which  has  been 
dusted  a  dry  powder.  This  acutely  flexed  position  is  maintained 
by  an  adhesive-plaster  strap,  three  inches  wide,  passing  about  the 
arm  and  forearm  (see  Fig.  221).      This  strap  should  be  placed 


Fig.  221. — Left  elbow  in  position  of  forced  flexion.  Gauze  in  bend  of  elbow.  Thin  axil- 
lary pad.  Pad  under  band  and  wrist.  Gauze  protection  under  forearm,  held  by  safety-pin 
from  slipping.  Adhesive  plaster  maintaining  flexion.  Skin  protected  on  upper  arm  by 
gauze.compress  from  cutting  of  adhesive  plaster. 


upon  the  upper  arm  as  high  as  the  axillary  fold,  and  upon  the 
forearm  just  above  the  styloid  of  the  ulna.  A  piece  of  linen  or 
compress  cloth  (cotton  cloth)  is  placed  under  the  forearm  and 
hand  where  they  would  come  in  contact  with  the  skin  of  the 
(lust.  This  should  be  pinned  so  as  not  to  slip  from  position. 
The  arm  thus  flexed  is  supported  by  a  swathe  sling  (see  Fig.  213) 
made  of  cotton  cloth,  fifteen  inches  wide,  folded  three  times,  and 


TREATMENT  OF  FRACTURES  OF  THE  ELBOW 


i/9 


long  enough  to  extend  twice  around  the  body.  This  is  applied 
as  illustrated  (see  Figs.  222,  223).  The  elbow  is  held  to  the 
side  by  pinning  a  strip  of  compress  to  the  swathe  at  the  elbow 
and  posteriorly  (see  Fig.  223). 

Precautions  in  Using  the  Acutely  Flexed  Position  :  The  arm  is 
inspected  each  day  for  the  first  week.  It  is  necessary  to  note 
whether  with  the  increase  in  the  swelling  the  flexion  of  the  arm 


Fig.  222. — Applying  figure-of-eight  cravat  to  flexed  elbow  (after  Lund). 


should  be  diminished,  and  whether  with  diminution  in  the  swell- 
ing flexion  may  be  increased  with  safety.  The  radial  pulse 
should  be  felt  as  the  flexion  is  diminished,  so  as  to  avoid  com- 
pression of  the  vessels  at  the  bend  of  the  elbow.  There  should 
be  no  pain  associated  with  this  acutely  flexed  position.  A  cer- 
tain amount  of  discomfort  may  be  complained  of.  Real  pain 
will  be  indicative  of  too  great  pressure,  and  if  it  is  present,  the 
forearm    should    be    less    acutely    flexed.      Chafing    should    be 


IcSO 


FRACTURES    OF    THE    HUMERUS 


looked  for  at  the  bend  of  the  elbow,  under  the  forearm  and 
hand  and  on  the  chest,  where,  if  necessary,  fresh  powder  and 
compress  cloth  should  be  placed.  The  edge  of  the  adhesive 
plaster  may  cause  chafing  of  the  skin  upon  the  posterior  sur- 
face of  the  forearm  and  upper  arm.  It  may  be  necessary  to 
place  beneath  the  plaster  small,  carefully  folded  compresses  of 
cotton  cloth  to  protect  the  skin  (see  Fig.  222). 


Fig.  223.— Strap  from 
elbow  to  cravat  to  prevent 
abduction  of  flexed  elbow. 


Fig.  224. — Fastening  figure-of-eight  cravat  over  folded 
Compress  on  opposite  side  of  chest.  Elbow  region  open  to 
inspection. 


Later,  in  changing  the  adhesive  plaster,  the  skin  may  be 
washed  with  alcohol  and  then  with  soap  and  water,  to  the  great 
comfort  of  the  patient.  The  alcohol  removes  all  adhesive  plas- 
ter sticking  to  the  skin.  If  the  adhesive  plaster  chafes  the  skin, 
as  it  so  often  docs  in  children,  it  will  be  necessary  to  place  a  bit 
of  gauze  under  the  adhesive  plaster  strips,  leaving  enough  of 
the   sticky  side  of  the  plaster  uncovered  to  catch    the  skin  and 


TREATMENT    OF    FRACTURES    OF    THE    ELBOW 


1 8 1 


thus  keep  it  from  slipping  entirely  loose.  The  carrying  angle 
of  the  arm  will  be  preserved  if  the  fragments  are  approximately 
reduced  ;  it  can  not  be  maintained  otherwise.  The  acutely  flexed 
position  reduces  the  fragments  in  the  fractures  under  considera- 
tion ;  therefore  it  will  preserve  the  carrying  angle. 

Transverse  Fracture  of  the  Shaft  above  the  Condyles. — There 
is  usually  an  overlapping  of  the  fragments.  This  is  evident  in 
the  backward  displacement  of  the  lower  fragment  and  forearm 
and  in  the  forward  displacement  of  the  upper  fragment. 


Fig.  225. — Fracture  of  the  elbow.  Application  of  the  internal  right-angle  splint.  First 
strap  already  applied.  Manner  of  holding  splint  and  arm  as  the  forearm  is  flexed  up  to  the 
splint  (see  Fig.  226). 


It  will  be  necessary  in  order  to  effect  reduction  of  this  frac- 
ture to  make,  with  the  aid  of  an  assistant,  countertraction  and 
pressure  backward  upon  the  upper  fragment  while  traction  and 
a  forward  pull  are  made  upon  the  lower  fragment  by  grasping  the 
arm  above  the  condyles  (see  Fig.  220).  The  internal  right- 
angle  splint  will  best  hold  this  fracture,  for  it  exerts  continuous 
pressure  backward  upon  the  upper  fragment  and  prevents  dis- 
placement (see  Figs.  225,  226).  It  is  padded  with  sheet  wad- 
ding and  applied  as  illustrated.      Two   straps  are  needed  upon 


I  82 


FRACTURES    OF    THE    HUMERUS 


the  forearm  to  hold  this  splint  in  good  position  (see  Figs.  227, 
228).  The  strap  at  the  wrist  should  be  so  applied  that  there  is 
no  pressure  upon  the  styloid  process  of  the  ulna.  Long-continued 
pressure  upon  this  bony  process  would  cause  a  pressure  sore. 
In  applying  the  adhesive  plaster  it  is  wise  to  apply  it  so  loosely 
that  there  is  no  undue  pressure  upon  the  arm,  which  might  re- 
tard the  circulation.  The  arm  is  then  covered  with  a  roller 
bandage  of  sheet  wadding,  over  which  is  placed  a  roller  bandage 
of  cheese-cloth.  This  should  be  applied  smoothly  and  firmly 
from  the  hand  to  the  upper  end  of  the  splint.      As  the  swelling 


Fig.  226. — Fracture  of  the  elbow.     Application  of  the  internal  angular  splint.     Placing  second 
strap.     The  angle  of  the  splint  is  crowded  into  the  bend  of  the  elbow  (see  Fig.  225). 


about  the  elbow  begins  to  subside,  pads  of  cotton  cloth  (com- 
press cloth)  may  be  placed  at  each  side  of  the  olecranon  below 
each  condyle.  The  pressure  of  a  frequently  renewed  bandage 
on  these  pads  will  hasten  the  disappearance  of  the  swelling.  It 
is  important  to  avoid  the  forward  and  backward  deformity  in 
treating  this  fracture  (see  Figs.  229,  230,  231). 

Dislocation  of  Both  Bones  of  the  Forearm  Backward. — If  there 
is  no  tendency  to  displacement  after  reduction  is  accomplished, 
the  right-angle  position  with  internal  splint  is  the  best  treatment. 
If,  on  the  other  hand,  there  is  a  tendency  to  displacement,  the 
acutely  flexed  position  will  be  the  best  for  the  arm  because  in 


TREATMENT  OK  FRACTURES  OF  THE  ELBOW 


I83 


case  the  coronoid  process  is  broken  it  will  insure  its  close  approxi- 
mation to  the  ulna. 

Separation  of  tlie  lower  epiphysis  of  the  humerus  will  be  best 
treated  in  the  right-angle  position,  the  same  as  a  fracture  of  the 
humerus  above  the  condyles  (see  Figs.  210  and  212). 

Fracture  of  the  neck  of  the  radius  is  best  treated  by  the  internal 
right-angle  splint. 

Fracture  of  the  olecranon  is  discussed  elsewhere. 

The  After-care  of  Injuries  to  the  Elbow. — The  reapplying 
of  splints  and  of  apparatus  should  be  done  often  enough  to  be  sure 


Fig.  227. — Two  straps  insufficient  to  hold 
elbow  in  internal  right-angle  splint.  Splint 
has  slipped  away  from  the  bend  of  the  elbow. 


Fig.  228. — Third   strap  is  necessary  to  hold 
the  splint  close  to  the  flexed  elbow. 


that  they  are  efficient,  and  that  there  is  no  undue  swelling  or 
pressure  upon  the  arm.  Rebandaging  the  hand  and  the  arm 
each  day,  if  the  internal  angular  splint  is  used,  is  important.  All 
apparatus  should  be  removed  at  least  once  a  week,  and  carefully 
inspected  twice  during  this  interval.  Passive  motion  should  be 
instituted  late  rather  than  early.  In  most  instances  it  will  be 
wise  to  delay  passive  motion  until  union  is  firm — from  the  fourth 
to  the  sixth  week.  It  should  be  of  the  gentlest  sort  ;  passive 
motion  that  is  painful  does  harm. 

Massage  to  the  hand,  wrist,  forearm,  elbow,  and   upper  arm, 


1 84 


FRACTURES    OF    THE    HUMERUS 


after  the  primary  swelling  has  begun  to  subside,  is  of  great  value. 
It  should  be  given  at  first  without  disturbing  the  apparatus  and 
the  retentive  adhesive  plaster.  Given  every  other  day,  it  will 
accomplish  considerable  in  maintaining  the  integrity  of  the 
muscles  of  the  part.      The  employment  of  a  professional   mas- 


1'  ig.  229. — Supi  acondyloid  fracture.  Ob- 
liquity of  the  line  of  fracture  from  behind 
downward  and  forward.  Diagram  show- 
ing anterior  deformity  with  elbow  flexed. 


Fig.  230. — Supracondyloid  fracture.  Ob- 
liquity of  the  line  of  fracture  from  above- 
downward  and  backward.  Diagram  show- 
ing posterior  deformity  if  acute  flexion  of 
forearm  is  attempted. 


Fig.  231.— Supracondyloid  fracture  with  slight  anterior  displacement,  wired.  Recoverv, 
with  slight  anterior  bending  of  fragments.  Wire  seen  in  situ  (X-ray  tracing.  Massachusetts 
General  Hospital,  1077). 


seuse  is  not  always  necessary.      The   physician   should  give  the 
massage  or  instruct  a  competent  person  how  to  give  it. 

(  'mission  of  Splint  or  Retentive  Apparatus  :  This  should  be 
tentative  and  gradual  after  union  is  known  to  be  firm — in  the 
fifth  or  sixth  week.  The  arm  should  be  allowed  in  a  sling  with- 
out the  splint  for  an  hour  and  then  the  splint   applied.      The  fol- 


THE    PROGNOSIS    OF    FRACTURES    OF    THE    ELBOW 


I  8 


lowing  clay  a  longer  interval  is  granted  without  the  splint. 
Gradually,  the  splint  is  removed  entirely.  A  snugly  fitting  band- 
age will  often  prove  comfortable  as  a  support  on  first  leaving  off 
the  splint.  Passive  motion,  massage,  and  active  use  of  the  arm  will 
now  assist  in  regaining  the  use  of  the  joint.  At  this  stage  the 
carrying  of  dumb-bells,  pails  or  baskets  filled  with  sand,  and  the 
doing  of  certain  gymnastic  movements  with  the  injured  arm 
will  be  of  material  aid.  All  violent  exercise  of  the  part  is  to 
be   avoided.      That   amount   of   exercise    may   be   allowed  that 


Fig.  232. — Diagram  to  show  the  amount  of  the  limitation  of  extension  that  may  be  caused 
by  very  moderate  callus  (a)  in  the  olecranon  fossa,  without  displacement  of  fragments  (median 
section  of  dry  bones). 


leaves  the  arm  moderately  tired.   A  fatigue  that  is  not  recovered 
from  within  a  half-hour's  rest  is  excessive. 

The  Prognosis. — Up  to  the  time  of  the  present  introduction 
of  the  acutely  flexed  position  in  the  treatment  of  fractures  at  the 
elbow,  the  movement  most  easily  lost  and  with  greatest  difficulty 
regained  was  that  of  flexion.  By  the  use  of  the  acutely  flexed 
position  in  suitable  cases  the  prognosis  has  improved  remarkably 
in  this   respect.      Now  all   of  flexion  is  ordinarily  preserved,  and 


1 86  FRACTURES    OF    THE    HUMERUS 

the  more  easily  acquired  extension  is  obtained  as  usual,  so  that 
the  prognosis  as  to  motion  in  these  cases  is  good.  Although  ana- 
tomically perfect  results  are  not  always  obtained,  most  fractures 
of  this  region  recover  with  a  useful  arm.  These  fractures  of  the 
elbow  region  should  be  kept  under  observation  for  at  least  four 
months.  It  is  wise  to  treat  such  cases  until  all  that  can  be 
achieved  toward  a  restoration  of  function  has  been  accomplished. 
At  the  time  of  the  first  examination  of  the  elbow  the  nature 
of  the  injury  and  its  seriousness  should  be  explained  care- 
fully to  the  patient  or  his  friends.  A  guarded  outlook  should 
be  expressed,  particularly  with  reference  to  the  function  of  the 
joint.  Some  limitation  of  motion  may  exist  after  all  that  is  pos- 
sible has  been  done  (see  Fig.  232).  How  much  limitation  of  mo- 
tion will  exist  it  is  impossible  to  state.  There  may  be  none  what- 
ever. The  patient  and  his  friends  should  be  encouraged  with  the 
statement  that  just  as  great  usefulness  of  the  elbow-joint  will  be 
obtained  as  is  consistent  with  the  character  of  the  injury.  The 
importance  of  the  injury  demands  of  every  physician  a  painstak- 
ing anatomical  examination  with  the  aid  of  an  anesthetic,  careful 
attention  to  minute  details  in  the  initial  treatment,  and  intelligent 
solicitude  in  the  after-care  of  all  traumatisms  to  the  elbow-joint. 


CHAPTER  X 
FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

FRACTURES  OF  BOTH  RADIUS  AND  ULNA 

The  most  common  seats  of  fracture  are  in  either  the  middle 
or  lower  thirds  of  the  bones.  The  fracture  of  the  radius  is 
often  a  little  higher  than  the  fracture  of  the  ulna  (see  Figs.  233— 
238  inclusive). 

Symptoms. — The  arm  can  not  be  used  without  pain.  In  a 
muscular  or  fat  arm  with  little  separation  of  the  fragments  there 
may  be  no  deformity  excepting  the  localized  swelling  at  the  seat 
of  fracture.  Deformity  will  be  determined  by  the  displacement 
of  the  bones.  If  the  seat  of  fracture  is  not  obvious,  the  fore- 
arm should  be  grasped  by  the  two  hands  (see  Fig.  239)  and 
gentle  but  firm  movement  attempted,  to  determine  the  pres- 
ence of  abnormal  motion  and  crepitus.  Motion  should  be  at- 
tempted in  all  directions,  for  the  bones  may  be  fractured  and 
yet  be  locked  when  movement  is  made  in  one  direction  only. 

Incomplete  or  Greenstick  Fracture  of  the  Bones  of  the 
Forearm  (see  Figs.  240,  241,  242). — This  is  a  partial  break 
across  the  bone,  with  bending  at  the  seat  of  fracture.  In  children 
between  the  ages  of  two  and  fourteen  years  injury  to  the  bones 
of  the  forearm  results  usually  in  a  greenstick  fracture.  Either 
one  or  both  bones  may  be  broken.  One  bone  may  be  completely 
fractured  while  the  other  is  incompletely  broken. 

Deformity  is  very  evident.  Pain  and  tenderness  at  the  seat 
of  fracture  are  present.  Crepitus  is  absent  unless  one  bone  is 
completely  fractured.  Children  having  these  fractures  are  often 
seen  a  week  or  two  after  the  injury  ;  they  are  said  to  have 
"  sprained  the  arm  "  and  "  are  unable  to  use  it  well  at  the  pres- 
ent time."  Careful  inspection  will  detect  the  characteristic  bow- 
ing at  the  seat  of  a  greenstick  fracture.  Slight  callus  will  be 
present  if  a  little  time  has  elapsed  since  the  injury. 

187 


INN 


FRACTURES  OK  BOTH  RADIUS  AND  ULNA 


189 


Fracture  of  the  Neck  and  Head  of  the  Radius. — These 
fractures  are  rarely  unassociated  with  lesions  of  the  humerus  and 
ulna.  A  fracture  of  the  external  condyle  of  the  humerus  and 
backward  dislocation  of  both  bones  of  the  forearm  have  been 
noted  with  these  fractures. 


Fig.  234. — Fracture  of  both  bones  of  the  forearm. 


Local  swelling  and  tenderness  over  the  radial  head  and  neck 
are  apparent.  The  swelling  is  greater  than  in  a  simple  subluxa- 
tion of  the  radius,  and  is  limited  to  the  upper  third  of  the  radial 
side  of  the  forearm.  There  is  pronation  of  the  forearm.  Flexion 
and  extension,  in  the  absence  of  associated  lesions  such  as  frac- 
ture of  the  external  condyle  of  the  humerus,  are  possible.     At- 


190 


FRACTl  'RES    OF    THE    BONES    OF    THE    FOREARM 


tempted  rotation  of  the  radius, — that  is,  supination, — elicits  pain, 
muscular  spasm,  and  perhaps  crepitus.  The  head  of  the  bone  does 
not  usually  rotate  with  the  shaft,  at  least  not  as  it  does  normally. 
Subluxation  of  the  radial  head  and  fracture  of  the  external  con- 
dyle of  the  humerus  are  the  two  lesions  with  which  a  fracture  of 
the  radial  neck  and  head  is  most  often  confused.  The  points  of 
difference  have  been  indicated.  The  X-ruy  is  here  of  decided  value. 
It  is  often  difficult  on  account  of  overlying  muscle  and  swelling 
of  the  soft  parts  to  palpate  the  head  of  the  radius  with  accuracy. 
Pressure  over  the   shaft   of  the  radius  at  about  its  middle  elicits 


Fig.  235. — Fracture  of  both  bones  of  the 
forearm  near  the  wrist,  at  about  the  same 
level.  Radial  displacement  of  whole  hand. 
Deformity  of  wrist  resembling  somewhat 
that  of  Colles'  fracture  (X-ray  tracing). 


Fig.  236.  — Fracture  of  both  bones  of  the 
forearm  near  the  wrist ;  different  levels.  No 
displacement  iti  either  place  (Massachusetts 
General  Hospital,  1384.    X-ray  tracing). 


pain,  if  a  fracture   of  the  radial  neck  be  present,  at  the  seat  of 
fracture.      An  X-ray  of  the  elbow  will  determine  a  diagnosis. 

Fracture  of  the  Shaft  of  the  Radius  (see  Figs.  246-251 
inclusive). — This  is  usually  caused  by  direct  violence.  The 
fracture  occurring  at  any  part  of  the  shaft  presents  no  unusual 
symptoms.  The  head  of  the  bone  does  not  rotate  with  the  shaft 
unless  tlie  fragments  are  locked.  Abnormal  mobility,  pain,  and 
crepitus  are  present.  The  displacements  vary  with  the  situation 
of  the  fracture.  Pronation  and  supination  will  be  limited  and 
painful.  This  fracture  has  been  mistaken  for  a  subluxation  of  the 
radial  head.      A  fracture  of  the  radial  shaft  at  the  junction  of  the 


FRACTURES    OF    BOTH    RADIUS    AND    ULNA 


191 


lower  and  middle  thirds  will  sometimes  suggest  very  plainly  the 
lateral  deformity  in  a  Colles'  fracture,  the  prominent  ulna  and 
apparently  shortened  styloid  process  of  the  radius  being  in  evi- 
dence. If  the  fracture  occurs  in  the  upper  third  of  the  bone, 
the  displacement  of  the  upper  fragment  will  be  considerable. 

Separation  of  the  Lower  Epiphysis  of  the  Radius  (see  Fig. 
252). — The  lower  radial  epiphysis  unites  to  the  shaft  of  the  bone 
at  the  twentieth  year.  Previous  to  this  age  a  separation  of  the 
epiphysis  is  not  at  all  uncommon.      Many  cases  of  separation  of 


^^1\^H)         Greater  sigmoid  cavity 
Radial  head.  f^\f     %/  of  the  ulna. 


Radial  shaft. 


Ulna  shaft. 


Fig.  237. — Common  displacement  in  fracture  of  the  neck  of  the  radius  (after  Mouchet). 


this  epiphysis  are  thought  to  be  Colles'  fractures,  and  they  are 
treated  as  such.  The  treatment  of  the  two  conditions  is  much 
the  same,  but  there  is  less  difficulty  in  maintaining  the  frag- 
ments in  position  in  separation  of  the  epiphysis,  and  the  epiphyseal 
separation  requires  a  shorter  time  in  splints. 

A  soft,  cartilaginous  crepitus  is  felt.  There  are  usually  less 
swelling  and  less  pain  than  in  a  Colles'  fracture.  The  deformity 
is  quite  constant  :  a  prominence  near  the  carpus  on  the  dorsum  of 
the  wrist  and   a  prominence  higher  up  on  the  palmar  surface  of 


Fig.  23S. — Fracture  of  both  bones  of  the 
forearm  at  the  middle,  showing  falling  to- 
gether of  broken  ends  (X-ray  tracing). 


Fig.  239. — Fracture  of  both  bones  of  the 
forearm,  showing  differences  in  level  and 
that  the  seat  of  fracture  is  in  the  lower  third 
of  bones. 


Fig.  240. — Fracture  of   radius   alone.    Slight  lateral,  considerable  anteroposterior,  dis- 
placement.     The  fallacy  of  depending  upon  an  X-ray  taken  in  one  plane  only  is  here  illus- 
X-ray  tracing). 

192 


FRACTURES    OF    IiOTH     RADIUS    AND    ULNA 


193 


the  wrist.      There  is  almost  no  tendency  to  reproduction  of  the 
deformity  after  it  is  once  reduced. 

Fracture  of  the  shaft  of  the  ulna  occurs  usually  because  of 
a  direct  blow  received  upon  the  arm  raised  for  protection.  It 
is  more  uncommon  than  fracture  of  the  radius  (see  Figs.  255,  256, 

257)- 

Localized  tenderness,  pain  upon  attempting  to  use  the  fore- 
arm, obscure  discomfort  in  the  arm  after  an  injury — these  may  be 
the  only  signs  of  fracture.  There  is  no  general  swelling  of  the 
forearm.  Ordinarily,  there  will  be  very  little  displacement, 
because  the  radius  serves  as  a  splint  for  the  broken  bone.    Crepi- 


Fig.  241. — Manner  of  grasping'  forearm  to  detect  the  presence  of  fracture.     Note  the  firmness 

of  grasp. 


tus  may  be  detected  if  the  ulna  is  grasped  between  the  fingers, 
placed  either  side  of  the  fracture,  and  motion  is  attempted.  The 
shaft  of  the  ulna  being  subcutaneous  throughout  its  entire  extent, 
the  tender  seat  of  fracture  can  be  easily  determined  (see  Fig.  258). 
Fracture  of  the  coronoid  process  of  the  ulna  is  associated 
with  backward  dislocation  of  the  ulna.  It  is  a  rare  accident.  A 
very  small  fragment  is  broken  off,  and  it  is  not  much  displaced. 
If  in  any  dislocation  of  the  forearm  backward  recurrence  of  the 
deformity  after  reduction  occurs  readily,  a  fracture  of  the  coro- 
noid should  be  suspected.  This  will  be  confirmed  by  the  dis- 
covery of  a  small  hard  mass  in  front  of  the  elbow-joint  just 
above  the  insertion  of  the  brachialis  anticus  muscle  ;  roughly,  a 
13 


194 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


fingerbreadth  above  the  bend  of  the  elbow.  This  small  hard 
mass  may  give  crepitus  upon  being  manipulated.  It  is  very  diffi- 
cult to  detect  this  fragment  of  the  coronoid  process  even  under 
the  most  favorable  conditions.  The  Rontgen  ray  may  discover  it. 
Treatment  of  Fractures  of  the  Forearm. — The  objects  of 


m. 


FiK-  242.  —  Green- 
stick  fracture  of  both 
bones  of  the  forearm 
(diagram ). 


Fig.  243. — Greenstick  frac- 
ture of  both  bones  of  the  fore- 
arm. Notice  characteristic  de- 
formity (X-ray  tracing). 


Fig.  244. — Complete  frac- 
ture of  ulna  and  greenstick 
fracture  oi  radius  (X-ray  trac- 
ing). 


treatment  are  to  prevent  permanent  deformity  and  to  preserve 
the  movements  of  pronation  and  supination. 

Fractures  of  Both  Radius  and  Ulna. — All  fractures  of  the 
fon  arm  attended  with  overriding  or  angular  displacement  that  do 
not  yield  readily  to  traction,  co untertraction,  and  pressure  should 


Fig.  245. — Right  fore- 
arm bones  in  semipronation 
from  front  and  inner  side, 
showing  epiphyses  ;  child  of 
eight  years  (Warren  Mu- 
seum, specimen  3341. 


Fig.  246. — Fracture  of  radius. 
Slight  lateral  displacement.  See 
figure  247  (X-ray  tracing). 


Fig.  247. — Fracture 
of  radius.  Slight  an- 
teroposterior displace- 
ment (same  as  Fig.  246, 
X-ray  tracing). 


Fig.  24S. — Comminuted  fracture  of  ra- 
dius, low  down,  and  of  ulnar  styloid  (X-ray 
tracing). 


Fig.  249. — To  illustrate  so  great  damage 
to  lower  end  of  radius  that  complete  restor- 
ation to  normal  is  impossible  (X-ray  trac- 


195 


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TREATMENT 


19; 


be  reduced  under  complete  anesthesia.  While  an  assistant  makes 
countcrtraction  upon  the  upper  part  of  the  forearm  the  surgeon, 
holding  the  lower  end  of  the  limb,  makes  strong,  even  traction, 
at  the  same  time  pressing  the  bones  into  position.  When  the 
angular  deformity  is  corrected,  the  forearm  should  be  strongly 
supinated.  This  supination  will  assist  in  preventing  the  bones 
becoming  locked  close  together  (see  Fig.  26 l). 

In  order  to  immobilize  a  fracture  of  the  shaft  of  a  bone  not  only 
must  the  fracture  itself  be  held  firmly,  but  the  joint  immediately 


Fig.  252.— Oblique  fracture  of  the  shaft  of 
the  radius. 


Fig.  253.— Separation  of  the  lower  epiphy- 
sis of  the  radius  without  displacement. 


above  and  below  the  seat  of  fracture  must  be  immovably  fixed. 
If  the  arm  is  seen  immediately  after  the  accident,  and  the  soft 
parts  are  not  evidently  bruised,  and  there  is  little  swelling,  a 
plaster-of- Paris  splint  should  be  applied.  It  should  extend  from 
the  axilla  above  to  the  metacarpophalangeal  joints  below.  The 
arm  should  be  flexed  to  a  right  angle  and  the  forearm  semi- 
supinated  (thumb  upward)  (see  Fig.  262). 

Precautions  in  Using  the  Plaster-of-Paris  Splint :  The  forearm 
should  be  held  in  the  corrected  position  by  an  assistant  through- 
out the  application  of  the  plaster  bandages.      Two  assistants  will 


198 


FRACTURES  OF  THE  HONES  OF  THE  FOREARM 


facilitate  the  putting  on  of  the  plaster.  The  forearm  and  upper 
arm  should  be  thinly  covered  with  one  layer  of  sheet  wadding  ; 
cotton  wadding  should  not  be  used.  No  salt  should  be  used  in 
the  water  in  which  the  plaster  bandages  are  dipped.  It  will 
require  about  three  or  four  bandages,  three  inches  wide  and  four 
yards  long,  for  an  ordinary  muscular  adult  arm.  The  plaster 
roller  should  be  applied  deliberately,  evenly,  and  snugly  from 
the  metacarpophalangeal  joints  to  the  axilla.  Great  lateral  com- 
pression of  the  arm  will  be  avoided  if  the  bandage  is  applied  as 


Fig.  254. — Old  fracture  of  both  bones 
of  the  forearm;  pseudoarthrosis  of  ulna. 
Radial  fracture  has  united  (X-ray  tracing). 


Fig.  255. — Fracture  of  the  shaft  of  the 
ulna.  Slight  lateral  displacement.  Local- 
ized tenderness  clinically  the  only  symp- 
tom (Massachusetts General  Hospital,  1036. 
X-ray  tracing). 


directed.     There  will  be  insufficient  compression  to   crowd  the 
bones  together  and  so  produce  deformity. 

After-care  of  the  Plaster  Splint :  When  the  plaster  has  set 
firmly,  the  assistant  may  place  the  forearm  in  a  sling  of  comfort- 
able height  to  support  the  arm.  Inspection  of  the  fingers  will 
determine  the  condition  of  the  circulation  in  the  limb.  If  there 
is  too  great  pressure,  if  the  splint  is  too  tight,  a  blueness  will  ap- 
pear, indicating  a  sluggishness  in  the  circulation.  If  this  sign  ap- 
pears, the  splint  should  immediately  be  split  from  axilla  to  hand 


TREATMENT 


\Cjij 


by  a  knife.  This  will  relieve  the  circulation.  Ordinarily,  there  is 
no  difficulty  of  this  sort.  The  patient  should  be  seen  each  day  for 
the  first  week  after  the  dressing  is  put  on.  Inquiry  should  be 
made  for  pain  and  throbbing  in  the  arm  and  sleeplessness,  which 
are  evidences  of  too  great  pressure.  If  the  arm  is  doing  well, 
the  splint  should  cause  no  discomfort.  After  one  week  the 
plaster  splint  should  be  removed,  for  the  swelling  of  the  arm 
will  have  diminished  and  the  splint  will  have  become  loosened. 
Unless  this  loosening  is  corrected,  an  opportunity  for  deformity  to 


Fig.  256. — Fracture  of  the  shaft  of  the 
ulna  from  direct  violence.  No  crepitus  de- 
tected. Local  swelling  and  tenderness  the 
only  symptoms  (X-ray  tracing). 


Fig.  257. — Fracture  of  ulna,  low  down, 
with  considerable  lateral  displacement  and 
shortening  of  shaft  (X-ray  tracing.  Massa- 
chusetts General  Hospital,  5693). 


occur  will  then  exist.  Either  a  new  plaster  should  be  applied  or 
the  old  splint,  if  suitable,  should  be  reapplied  and  tightened  by  a 
bandage.  If  the  splint  is  too  large,  it  may  be  made  smaller  by 
removing  a  strip  of  plaster  the  entire  length  of  the  splint.  The 
edges  of  the  cut  plaster  should  be  bound  with  strips  of  adhesive 
plaster  to  prevent  chafing  of  the  skin  and  crumbling  of  the  plaster. 
The  position  of  the  bones  at  the  seat  of  fracture  should  be  noted. 
The  degree  of  movement  possible  at  the  seat  of  fracture  should 
be  noted.     At  the  end  of  each  week   the  splints  should  be  re- 


200 


FRACTURES    OF    TiiF    HONKS    OF    THK    FORKARM 


moved.  After  about  three  weeks,  when  union  is  well  advanced, 
the  plaster  splint  may  be  cut  off  below  the  elbow  and  the  upper 
part  discarded,  or  a  posterior  splint  of  wood  may  be  applied  for 
lightness  and  convenience. 

If  the  force  was  a  direct  violence  and  there  is  injury  to  the  soft 
parts,  if  the  swelling  is  considerable  and  is  likely  to  be  greater,  it 
will  be  best  to  use  palmar  and  dorsal  splints  of  wood  upon  the 
forearm  and  an  internal  right-angle  splint  at  the  elbow.  The 
forearm  is  held  in  the  position  of  semisupination.  The  maximum 
swelling  occurs  within  the  first  forty-eight  hours — barring,  of 


Ulna. 


Radius. 


Fig.  258. — Partial  fracture  of  ulna.  T- 
shaped  line  of  the  fracture  (Warren  Mu- 
seum, 3722). 


Fig.  259.— Showing  distance  between 
hones  and  their  relation  to  mass  of  soil 
parts.  Median  section  of  forearm  (from 
frozen  section  by  Dwight). 


course,  inflammatory  disturbances,  which  are  not  to  be  considered 
here.  The  splints  should  be  of  thin  splint  wood,  which  is  stiff 
enough  not  to  yield  to  ordinary  pressure.  In  width  the}'  should  be 
one-fourth  of  an  inch  wider  than  the  forearm.  The  posterior  splint 
should  extend  from  just  above  the  middle  of  the  forearm  to  the 
metacarpophalangeal  joints.  The  anterior  splint  should  extend 
from  the  same  point  on  the  forearm  to  the  middle  of  the  palm  of 
the  hand  (sec  Fig.  261).  The  palmar  splint  is  cut  out  on  the 
thumb  side,  so  as  to  avoid  pressure  on  the  thenar  eminence. 
These  two  splints  are  padded  with  evenly  folded  sheet  wadding 
no  wider  than  the  splints.      About   three   or   four  thicknesses  of 


TREATMENT 


20I 


the  sheet  wadding  will  be  necessary.  The  ^posterior  splint  is 
padded  alike  through  its  whole  extent.  The  anterior  splint  is  so 
padded  as  to  conform  to  the  irregularities  of  the  anterior  surface 
of  the  forearm,  particularly  at  the  radial  side  near  the  wrist.  The 
internal  right-angle  splint  is  padded  evenly  with  four  thick- 
nesses of  sheet  wadding.  It  overlaps  the  wooden  splints,  and 
extends  up  to  the  axilla.      It  immobilizes  the  elbow-joint. 


Fig.  260. — Variations  in  the  shape  and  width  of  the  interosseous  space  between  radius  and 
ulna  when  the  forearm  is  supinated,  pronated,  and  setnipronated.  Semipronation  presents 
the  widest  interosseous  space  (diagram). 


The  Application  of  the  Splints  :  The  forearm  is  held  flexed  at 
a  right  angle  and  semisupinated  and  steadied  by  an  assistant. 
The  posterior  and  then  the  anterior  splints  are  applied  to  the 
forearm.  Three  straps  of  adhesive  plaster,  two  inches  broad, 
are  then  applied — one  at  the  upper  ends  of  the  splints,  one  at  the 
wrist,  and  the  third  across  the  palm  of  the  hand  and  around  the 


!02 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


posterior  splint  only.  These  straps  should  simply  steady  the 
splints  snugly  in  position  (see  Fig.  262).  The  bandage  is 
next  applied,  and  it  is  by  this  that  pressure  is  exerted  upon  the 
arm.  There  should  be  some  spring  left  upon  pressing  the 
splints  together  after  the  bandage  is   applied.      If  there   is   none 


Fig.  261. — Fracture  of  the  forearm  low  down,  or  Colles'  fractuie.     Anterior  and  posterior 
splints,  three  straps,  radial  pad.     Antei  ior  splint  cut  out  to  fit  thenar  eminence. 


Fig.  262.— Fracture  of  the  forearm.     Manner  of  holding  arm  and  of  applying  the  adhesive- 
plaster  straps.     Posterior  splint  of  splint  wood, 


remaining,  too  great  pressure  will  be  made  on  the  arm  and  the 
circulation  will  be  interfered  with.  The  arm  is  placed  in  a  sling 
of  comfortable  height  (see  Fig.  263). 

If  the  fracture  of  the  forearm  is  above  the  middle  of  the  bones, 
the  tin  internal  right-angle  splint  should  be  used  to  immobilize  the 


TREATMENT 


203 


elbow-joint.  This  should  be  applied  after  the  wooden  splints 
are  in  place  and  while  the  arm  is  semisupinated.  A  bandage  is 
then  placed  over  both  wooden  and  tin  splints  (see  Figs.  264,  265, 
266). 

After-care  of  Wooden  and  Tin  Splints  :  The  patient  should  be 
seen  every  day  for  two  or  three  days  after  the  fracture.  The 
splints  should  be  readjusted  and  applied  more  snugly  by  a  fresh 
bandage.      The   comfort    of  the  patient  should   be  considered  ; 


Fig   263. — Fractureof  both  bones  of  the  forearm.     Proper  position  of  arm  in  sling.     Note  hand 
is  unsupported  by  sling,  and  arm  rests  on  ulnar  side.     Notice  height  of  arm. 


any  complaint  on  the  part  of  a  sensible  individual  should  be 
inquired  into.  If  the  apparatus  is  applied  with  the  bones  in 
approximately  normal  position,  there  should  be  no  subsequent 
discomfort.  All  splints  should  be  removed  at  least  twice  a  week 
throughout  active  treatment,  and  the  presence  of  deformity  noted 
and  corrected.  After  the  first  week  or  week  and  a  half,  the 
swelling  having  subsided,  it  is  often  advantageous  to  apply  in 
place  of  these  splints  of  wood  the  plaster-of- Paris  splint,  which 
has  been  described  (see  p.   197). 


204 


FRACTURES    OF    THE    BONES    OF    THE    FOREARM 


Fracture  of  the  head  and  neck  of  the  radius  and  fracture 
of  the  coronoid  process  of  the  ulna  should  be  treated  by  the 
internal  right-angle  splint  with  the  forearm  semipronated — that 
is,  with  the  thumb  up  (see  Fig.  266). 

Fracture  of  the  shaft  of  the  radius,  if  above  the  middle  of 
the  bone,  should  be  treated  by  the  anterior  and  posterior  wooden 
splints  and  the  internal  right-angle  splint.  If  below  the  middle 
of  the  bone,  the  internal  right-angle  splint  may  be  omitted, 
although  it  may  be  well  to  retain  it  in  most  instances.  If  the 
fracture  is  in  the  upper  third   of  the  bone,  it  may  be  impossible 


Fig.  264. — Fracture  of  both  bones  of  the  forearm.  Ulnar  view  of  the  anterior  and  pos- 
terior splints.  Note  length  of  splints  and  position  of  straps.  Straps  of  the  internal  right- 
angle  splint,  3  and  4. 

to  correct  the  deformity  without  making  an  open  fracture  and 
suturing  the  fragments  together.  It  may  be  possible  to  ap- 
proximate the  fragments  by  putting  the  forearm  in  a  position  of 
semipronation.  No  especial  splint  is  necessary  to  maintain  this 
position  ;  the  two  wooden  anterior  and  posterior  splints  and  the 
tin  internal  right-angle  splint  fulfil  all  the  indications. 

Separation  of  the  lower  radial  epiphysis  is  treated  by  ante- 
rior and  posterior  splints,  similarly  to  the  treatment  of  a  Colics' 
fracture  (see  Fig.  261). 

Fracture  of  the  shaft  of  the  ulna  should  be  treated  as  frac- 
tures of  the  shaft  of  the  radius  are  treated. 


TREATMENT 


20s 


How  long  should  splints  be  kept  on  in  fractures  of  the  fore- 
arm ?  Until  union  is  firm  enough  between  the  fragments,  so  that 
firm  pressure  does  not  cause  motion.  When  the  fracture  is  firm, 
ordinarily  after  about  three  weeks  and  a  half,  the  anterior  and  in- 
ternal angular  splints  may  be  omitted,  the  posterior  splint  alone 
being  left  in  place.  If  the  posterior  splint  of  wood  is  used,  a 
broad  (four-inch)  strap  of  adhesive  plaster,  in  addition  to  the  two 
ordinary  straps  at  each  end  of  the  splint,  should  be  placed  at  the 
seat  of  fracture  and  a  gauze  bandage  applied  over  all.      At  the 


Fig.  265. — Fracture  of  the  bones  of  forearm.  Forearm  siipinated.  Anterior  and  posterior 
splints  and  tin  internal  angular  splints.  1  and  2,  Straps  holding  anterior  and  posterior  splints  ; 
3,  4,  and  5,  straps  holding  internal  right-angle  splint. 


end  of  the  fourth  or  fifth  week  all  splints  should  be  omitted. 
Continual  watchfulness  is  demanded  in  order  that  bowing  at  the 
seat  of  fracture  may  not  take  place.  The  application  of  the 
sling  after  the  omission  of  splints  should  be  carefully  made  to 
avoid  backward  bowing  of  the  bones.  A  laboring  man  should 
not  go  to  work  for  at  least  from  four  to  six  weeks  after  leaving 
off  splints.  A  return  to  work  too  early  causes  bowing  of  the 
fracture  and  pain  in  the  arm. 

Massage  and  passive  motion  should  be  employed  as  soon  as 
union  is   firm  and  the  anterior  and  internal  angular  splints  have 


206 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


been  removed.  Massage  may  be  given  at  first  without  removing 
the  arm  from  the  splint.  Convalescence  will  proceed  more  rap- 
idly in  consequence  of  massage. 

When  will  the  arm  be  restored  to  normal  usefulness  ?  It  is  im- 
possible to  answer  this  question  accurately.  The  conditions  in 
each  individual  instance  of  fracture  are  so  variable  that  no  gen- 
eral statement  can  be  made  that  will  more  than  indicate  the 
probable  time  of  convalescence.  It  may  be  fairly  stated  that  in 
an  uncomplicated  fracture  of  both  bones  of  the  forearm  the 
arm  will  be  useful  for  working  in  from  two  to  three  months 
from  the  time  of  fracture. 


Ii>;-  266. — Fracture  of  both  bones  of  the  forearm.  Anterior  and  posterior  splints  and  tin 
internal  right-angle  splint  immobilizing  elbow-joint.  Note  arm  in  semipronation,  "thumb 
up  "  ;  position  of  straps  ;  padding  of  internal  right-angle  splint. 


The  treatment  of  open  fractures  of  the  forearm  is  best  con- 
ducted by  methods  described  under  open  fractures  of  the  leg  : 
briefly,  absolute  cleanliness,  suturing  of  bones,  sterile  dressing, 
immobilization  of  the  part. 

Prognosis  and  Result  of  Treatment. — There  may  be  some 
limitation  of  supination  and  pronation  immediately  alter  the 
splints  are  removed.  As  the  callus  diminishes  and  with  persist- 
ent movements  of  the  arm  in  ordinary  use  this  limitation  should 
diminish,  and  in  some  instances  entirely  disappear.  If  the  frac- 
ture is  in  the  upper  or  lower  thirds  of  the  bones,  the  limitation 
of  motion  will    often  be  greater  than  when  tin-  fracture  is  at  the 


PROGNOSIS  AND  RESULT  OF  TREATMENT 


207 


middle  of  the  bones.  The  interosseous  space  is  greatest  at  the 
middle  of  the  shafts  (see  Fig.  260)  ;  consequently,  callus  at  this 
point  is  less  likely  to  impair  motion  of  the  forearm.  The  arm 
should  be  straight.  Movements  of  the  wrist  and  elbow  should 
be  perfectly  normal. 

Nonunion  of   Fractures. — If  after  the  usual  time  has  elapsed 
for  a  fracture  to  have  united  firmly  it  has  failed  of  union,  delayed 


Fig-.  267. — Application  of  sling.  Proper  position  of  triangular  bandage  in  first  step.  2  is 
carried  over  right  shoulder ;  1  drops  over  left  shoulder  :  r  and  2  are  fastened  behind  the  neck  ; 
3  is  brought  forward  and  pinned,  as  shown  in  figure  268. 


union  is  said  to  exist.  If  after  a  longer  time  no  union  occurs, 
nonunion  is  said  to  exist.  A  case  of  delayed  union  may  result 
in  nonunion  or  it  may  become  united.  The  term  nonunion 
does  not,  however,  necessarily  imply  that  no  union  exists  be- 
tween the  bones,  but  simply  that  bony  union  does  not  exist.  In 
cases  of  so-called  nonunion  fibrous  union  is  often  present. 
The    causes    of  nonunion   are  local  and  general.      Of  the   local 


Fig.  268-Applicatioti  of  sling.     Final  position  ol  arm.     Two  ends  tied  behind  neck  and  the 

third  end  pinned. 


Fij,'.  269.— Compound  fracture  and  dislocation  at  the  wrist.    Hand  saved. 

208 


PROGNOSIS  AND  RESULT  OF  TREATMENT 


'OO, 


causes  the  commonest  is  the  interposition  of  some  soft  tissue, 
such  as  torn  periosteum,  strips  of  fascia  or  muscle,  between  the 
fragments.  A  wide  separation  and  imperfect  immobilization  of 
the  fragments  are  also  factors  in  the  occurrence  of  nonunion. 
Of  the  general  causes  it  is  thought  that  syphilis,  pregnancy, 
prolonged  lactation,  the  wasting  diseases,  rachitis,  and  the  acute 
febrile  diseases  may  contribute  something  toward  nonunion. 

The  constitutional  treatment  of  nonunion  is  of  primary  impor- 
tance, together  with  reduction  and  absolute  immobilization  of  the 
fragments.  If  these  measures  fail  after  a  fair  trial,  a  rubbing"  of 
the  ends  of  the  fractured  bones  together  and  then  immobilizing- 


Fig.  270. — Method  of  applying  force  in  completing  a  greenstick  fracture  of  the  forearm.     The 
force  is  applied  in  the  direction  of  the  original  force  (diagram). 


them  is  sometimes  effective.  If  this  fails  too,  operative  meas- 
ures should  be  instituted  for  making  the  fracture  an  open  one 
for  the  removal  of  any  interposed  tissues.  Careful  fixation  will, 
after  such  operative  procedure,  usually  effect  union.  If  for 
some  unremediable  constitutional  reason  union  does  not  result 
after  operation,  a  splint  should  be  devised  to  make  the  damaged 
part  as  useful  as  is  compatible  with  nonunion. 

Treatment    of    Greenstick    or    Incomplete    Fracture   of    the 
Bones  of  the    Forearm. — It  is   impossible  to  maintain  the  cor- 
rection of  the   deformity  if  the  bones  are  simply  bent  back   into 
position.     Even  with  the  greatest  care  in  the  use  of  pads  and 
14 


2IO  FRACTURES    OF    THE    BONES    OF     THE    FOREARM 

pressure  the  deformity  will  in  part  reappear.  It  is  necessary, 
therefore,  to  administer  an  anesthetic,  and  to  make  a  complete 
fracture  of  the  greenstick  fracture.  This  done,  the  arm  is  set  as 
in  a  complete  fracture.  The  best  method  of  refracturing  the 
greenstick  fracture  is  to  bend  the  arm  with  the  two  hands  in  the 
direction  of  the  original  force  (see  Fig.  270). 

The  anterior  and  posterior  wooden  splints  may  be  used  with 
satisfaction.  Ordinarily,  the  plaster-of-Paris  splint  as  applied  in 
complete  fractures  is  the  best  apparatus.  Union  in  children  after 
fracture  is  more  rapid  than  in  adults.  At  the  end  of  two  weeks 
union  will  be  found  firm.  It  is  well  not  to  omit  all  apparatus 
in  a  child  until  four  weeks  have  passed.  If  great  caution  is 
needed  on  account  of  an  extremely  active  child,  the  posterior 
wooden  splint  should  be  kept  on  during  the  fifth  week. 


FRACTURES  OF  THE  OLECRANON 
The  normal  anatomical  relations  of  the  olecranon  should  be 
kept  constantly  in  mind.  The  insertion  of  the  brachialis  anticus 
muscle  is  into  the  front  and  lower  part  or  base  of  the  coronoid 
process  of  the  ulna.  The  insertion  of  the  triceps  muscle  is  into 
the  posterior  part  of  the  upper  surface  of  the  olecranon  and  into 
the  fascia  of  the  posterior  surface  of  the  forearm.  The  small 
epiphysis  of  the  olecranon  unites  to  the  shaft  about  the  sixteenth 
year.  A  direct  blow  upon  the  olecranon  together  with  violent 
muscular  contraction  of  the  triceps  will  produce  the  fracture.  The 
fracture  is  usually  transverse.  A  complete  transverse  fracture 
of  the  olecranon  always  opens  the  elbow-joint  (see  Fig.  271). 
Some  of  the  varieties  of  fracture  of  the  olecranon  are  seen  in 
the  accompanying  tracings  of  Rontgen-ray  plates  (see  Figs.  272, 
273,  274,  275). 

Symptoms. — Inability  forcibly  to  extend  the  forearm,  pain  at 
the  seat  of  fracture,  and  deformity,  provided  the  fragment  is 
separated  from  the  shaft  of  the  ulna.  A  depression  marks  the 
separation.  Very  great  separation  of  the  fragment  is  not  often 
present.  The  interval  between  the  fragments  depends  upon  three 
conditions  :  The  extent  of  the  facial  laceration — if  the  laceration 
is  moderate  in  extent,  the  interval  between  the  fragments  will  be 


FRACTURES  OF  THE  OLECRANON 


2  I  I 


slight ;   if  the  laceration   is  extensive,  the  interval  between   the 
fragments  may  be  great  ;   the  position  of  the  arm,  whether  flexed 


Fig.  271.— Showing  relations  of  olecranon  to  elbow-joint;  practically  all  fractures  are  intra- 
articular. 


Seat  of  fracture. 

Fig.  272.— Splintered  fracture  of  olecranon  without  much  displacement  (Massachusetts  Gen- 
eral Hospital,  1536.    X-ray  tracing). 


or  extended — if  flexed,  the  separation  will  be  greater  than  if 
extended  (see  Fig.  276) ;  the  amount  of  synovial  fluid  and  blood 
in  the  joint — the  greater  the  amount  of  fluid,  the  greater  will  be 


212 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


the  separation  of  the  fragments.      The  mobility  of  the  fragments 
of  the  olecranon  is  determined  by  grasping  the  olecranon  firmly 


Radius 


Coi'onoid  process 


1  Ilnar  shaft 


f—  Humerus. 


Olecranon 


Seat  of  fracture. 


Fig.  273. — Fracture  of  olecranon.     No  displacement  detected  clinically.     No  symptoms  other 
than  local  tenderness  and  slight  swelling  (X-ray  tracing). 


Humerus. 


Olecranon. 


I  '  1 11:11  shaft. 

Fig.  27.1.— Fracture  of  olecranon  ;  separation  of  fragments  upon  flexing  forearm  (X-ray 

tracing). 

and  attempting  lateral  motion  (see  Fig.  194).      Crepitus  may  thus 
be  elicited.     The  general  swelling  about  the  elbow    will  be  con- 


TREATMENT 


21 


siderable  if  the  traumatism  was  severe.     There  exists  a  traumatic 
synovitis  of  the  elbow-joint. 


Line  of  fracture. 

Fig.  275. — Fracture  of  olecranon  at  about  the  epiphyseal  line,  without  opening  the  elbow-joint 
(Massachusetts  General  Hospital,  1172.     X-ray  tracing). 


Fig.  276. — Diagrams  to  illustrate  separation  of  fragment  of  olecranon  by  the  triceps  and 
in  flexion  of  the  elbow. 


Treatment. — If  there  is  considerable  swelling  of  the  elbow, 
and  if  the  arm  is  large  and  muscular,  it  is  wise  to  rest  the  arm 
for  a  few  days  (at  least  five  or  six)  upon  an  internal  right-angle 


2  14 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


splint  before  putting  it  up  permanently.  The  swelling  will  dis- 
appear in  the  mean  time,  and  a  more  accurate  examination  of  the 
arm  can  then  be  made.  If  there  is  little  or  no  separation  of  the 
fragments  in  the  right-angle  position,  the  arm  may  be  kept  at  a 
right  angle.  This  is  doubtless  the  most  comfortable  position, 
and,  under  these  conditions,  certainly  is  effective.      If  there  is 


Fig.  .'77. —Fracture-  of  the  olecranon.     Arm  in  extension.     Long  anterior  splint.     Note  pad 
and  strap  above  olecranon  fragment ;  pad  in  palm  of  hand. 


marked  separation  (half  an  inch  or  more),  the  arm  should  be 
extended  and  this  position  maintained  by  a  long  internal  splint 
(see  Fig.  277).  This  splint,  made  of  splint-wood,  should  be  the 
width  of  the  arm,  and  should  reach  from  the  anterior  axillary 
margin  to  the  tips  of  the  fingers.  This  is  well  padded  with 
sheet  wadding  at  the  bend  of  the  elbow  (see  Fig.  278).  The 
contiguous  skin  surfaces  of  the  fingers  are  protected  from  chafing 


TREATMENT  21 5 

by  strips  of  gauze  or  compress  cloth  placed  between  them,  and  a 
pad  is  put  in  the  palm  for  comfort  (see  Fig.  279).  The  splint  is 
held  in  position  by  four  straps  of  adhesive  plaster,  one  placed  at 
either  end  of  the  splint  and  one  above  and  below  the  elbow-joint. 
The  upper  or  loose  fragment  is  pushed  down  toward  the  shaft  of 
the  ulna,  and  held  in  place  by  a  strap  of  adhesive  plaster  carried 


Fig.  278. — Fracture  of  olecranon.     Arm  in  extension.     Note  upper  and  lower  straps  ;  oblique 
olecranon  strap  ;  padding  of  splint. 


around  the  upper  side  of  the  olecranon  fragment  and  fastened  to 
the  splint  lower  down.  Sheet  wadding  and  gauze  roller  bandages 
applied  from  the  fingers  to  the  axilla  afford  comfort  and  prevent 
undue  swelling  of  the  hand.  Should  the  separation  be  so  great 
that  reduction  of  the  fragment  is  unsatisfactory,  an  incision  and 
suture  should  be  made  (see  Fig.  279). 

Treatment  if  the  Fracture  is   Open. — The   wound    should,   if 


2l6       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

necessary,  be  enlarged  to  permit  of  easy  inspection  of  the 
joint  surface.  The  joint  should  be  thoroughly  irrigated 
with  boiled  water.  The  wound  of  the  soft  parts  should  be 
very  thoroughly  cleansed  by  scrubbing  with  gauze  wet  in  cor- 
rosive sublimate  solution,  i  :  5000,  and  then  the  fragment  of 
the  olecranon  sutured  to  the  shaft. 


Fig.  279.— Fracture  of  olecranon.     Bandage  applied  to  the  same  case  as  shown  in  figures  277, 
27v-     Note  protection  of  fingers  from  chafing  by  compress  cloth  and  bandaging  of  hand. 

The  After=care. — If  the  arm  has  been  put  up  temporarily  at  a 
right  angle  to  await  the  subsidence  of  the  swelling,  gentle  mas- 
sage and  firm  bandaging  of  the  arm,  twice  daily,  until  the  swell- 
ing subsides  sufficiently  for  accurate  examination  and  a  more 
permanent  dressing,  will  be  of  very  great  service.  The  arm 
should  be  inspected  each  day  for  the  first  week.  Daily  massage 
should  be  continued  not  only  to  the  joint  region,  but  t<>  the  fore- 


TREATMENT 


217 


arm  and  upper  arm  as  well.  The  straps  and  bandages  should 
be  reapplied  as  they  become  too  tight  or  are  loosened  by  the 
disappearance  of  the  swelling.  After  about  two  weeks  the  posi- 
tion of  the  forearm  may  be  cautiously  changed.  The  small 
fragment  of  the  olecranon  should  be  held  fixed  during  the  ma- 
nipulation. If  the  arm  is  in  the  extended  position,  it  should 
be  gradually  flexed  some  five  or  ten  degrees,  and  returned 
to   the  extended    position.       If  the    arm  is    already  at  a  right 


Fig.  280. — Method  of  examination  of 
wrist.  Note  supination  of  forearm;  posi- 
tion of  examining  hands  and  fingers;  pal- 
pation of  the  styloid  process  of  the  radius 
and  the  head  of  the  ulna.  The  radial  sty- 
loid is  seen  to  be  lower  than  the  head  of 
the  ulna. 


Fig.  281. — Method  of  examination  of 
wrist.  Note  pronation  of  forearm  ;  posi- 
tion of  examining  hands  and  finyers  ;  pal- 
pation of  styloid  processes  of  radius  and 
ulna.  The  styloid  of  the  radius  is  lower 
than  the  styloid  of  the  ulna. 


angle,  it  should  be  gradually  extended,  at  first  a  few  degrees 
only,  and  returned  to  the  right-angle  position.  No  pain  should 
be  experienced  by  the  passive  motion.  Painful  passive  motion 
is  harmful.  After  a  few  days  of  these  gentle  passive  motions  it 
will  be  wise  to  alter  the  angle  of  the  splint  so  that  the  arm 
may  rest  in  the  changed  position  permanently.  After  about 
four  or  five  weeks  all  splints  should  be  omitted.  A  bandage 
should  be  worn  after  the  removal  of  the  splints  to  afford  support 
to  the  elbow. 


218 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


Union  of  the  fragments  usually  takes  place  in  from  three  to 
four  weeks.  After  six  weeks  to  three  months  the  movements  of 
the  elbow-joint  should  be  normal.  There  may  remain  as  a  per- 
manent condition  slight  limitation  of  extension.  The  functional 
usefulness  of  the  elbow  depends  more  upon  the  approximation 
of  the  fragments  and  less  upon  the  kind  of  union  between  them. 
The  union  between  the  fragments  is  more  often  ligamentous 
than  bony.  A  short  fibrous  union,  if  of  good  width, — i.  c,  if  it 
covers  the  whole  of  the  broken  surface, — is  as  efficient  as  a  bony 
union.     A  ligamentous  union  accompanied  by  great  disability  in 


Fig.  282. — a,  Tip  of  radius ;  b,  styloid  process  of  ulna;  c,  ulnar  head.  1.  Supination.  2. 
Pronation.  To  illustrate  tliat,  in  comparing  the  level  of  the  styloid  of  radius  with  lower  end 
of  ulna,  as  in  figures  280,  281,  in  supination,  1,  the  head  of  the  ulna  is  felt,  and  that  in  prona- 
tion, 2,  the  styloid  of  the  ulna  is  felt. 


the  functional  usefulness  ot  the  arm  should  be  excised  and  the 
bony  fragment  sutured  to  the  shaft.  Suturing  of  the  periosteum 
and  fibrous  tissue  about  the  fragments  will  prove  fully  as  satis- 
factory in  many  cases  as  suturing  the  bone  with  silver  wire. 

Summary  :  If  there  is  great  swelling,  delay  the  application 
of  the  permanent  splint.  Apply  internal  right-angle  splint. 
Use  compression  and  massage.  If  there  is  little  or  no  separa- 
tion of  the  fragments,  use  a  right-angle  splint.  If  there  is 
marked  separation  of  fragments,  use  an  extended  position.     If 


COLLES      FKACTUKI-: 


219 


the  fracture  is  open,  suture  the  fragments.  If  practicable,  at 
the  outset,  renew  the  bandage  and  massage  the  arm  twice  daily. 
After  two  weeks  cautious  passive  motion  should  be  made  daily. 
After  three  weeks  the  angle  of  the  splint  should  be  permanently 
changed.  After  four  weeks  all  splints  should  be  removed. 
After  six  weeks  to  three  months  a  useful  arm  should  result. 

Tetanus  is  rarely  seen  after  fracture  of  bone.  It  sometimes 
appears  after  open  fracture.  Early  amputation  and  the  adminis- 
tration of  tetanus  antitoxin  are  the  most  rational  means  of  treat- 
ment in  these  cases. 

COLLES'  FRACTURE 

A  fracture  of  the  lower  end  of  the  radius  within  about  one 
inch  of  the  articular  surface  is  common  in  adults  and  is  unusual 
in  childhood.  A  fall  upon  the  outstretched  and  extended  hand 
is  the  most  frequent  cause. 

Anatomy. — In  a  case  of  traumatism  to  the  wrist  the  normal 


Fig.  283. — Method  of  examination  in  a  case  of  injury  to  the  lower  end  of  the  radius.     Grasp- 
ing the  radius  above  and  below  {he  probable  seat  of  fracture. 


anatomical  relations  should  be  studied  upon  the  uninjured  wrist, 
and  then  a  careful  examination  made  of  the  injury.  The  normal 
wrist  should  be  looked  at  from  the  front  and  back  and  from  each 
side  with  the  hand  supinated.  Anteriorly,  the  base  of  the  thenar 
eminence  is  lower  than  that  of  the  hypothenar  eminence.  Pos- 
teriorly, on  the  inner  side,  the  styloid  process  of  the  ulna  is 
visible  with  the  marked  depression  below  it.  Laterally,  on  the 
radial  side,  is  seen  the  curve  backward  on  the  anterior  surface  of 


220 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


the  radius  where  the  base  of  the  styloid  process  of  the  radius 
joins  the  shaft.  Laterally,  upon  the  ulnar  side,  are  seen  not  only 
the  styloid  of  the  ulna  and  its  associated  depression,  but  the 
hollow  above  the  prominence  of  the  hypothenar  eminence. 

The  normal  wrist  should  be  felt  with  the  hand  both  in  supina- 
tion and  pronation.  With  the  hand  supinated  (see  Fig.  280)  the 
tip  of  the  styloid  process  of  the  radius  is  found  to  be  lower 
(nearer  the  hand)  than  the  head  of  the  ulna.  With  the  hand  in 
pronation  (see  Fig.  281)  the  tip   of  the  styloid  process  of  the 


Fig.  284. — Diagram  of  fracture  of  base  of   radius   with   anterior  displacement:   "reversed 
Colles'  fracture"  (term  suggested  by  Roberts). 


Fig.  285. — Colles'  fracture :  the  common  "silver-fork  deformity."     Note  dorsal  and  palmar 
prominences  (diagram). 


radius  is  found  to  be  a  little  lower  (nearer  the  hand)  than  the  tip 
of  the  styloid  process  of  the  ulna.  To  ascertain  the  relative  posi- 
tion of  the  styloid  processes,  the  injured  wrist  should  be  grasped 
by  the  two  hands  and  the  styloids  felt  by  the  tips  of  the  fore- 
fingers. The  styloid  process  of  the  radius  and  the  shaft  imme- 
diately above  it  should  be  carefully  palpated  to  determine  the 
extreme  thinness  of  the  bone  above  the  thick  styloid  process 
(see  Fig.  283).       The  width  of  the  wrist  between  the  styloid  pro- 


COLI.FS      FRACTURE ANATOMY 


2  2  I 


cesses  should  be  measured  by  means  of  a  tape,  or,  better,  by  a 
pair  of  calipers. 

The  movements  of  the  normal   wrist  and  forearm  should  be 
carefully  observed.      Pronation   and   supination   of  the  forearm 


Fig.  286. — Colles'  fracture.     Characteristic  appearance.     Note  backward  displacement  of  the 
hand  and  wrist.     Palmar  prominence.     Compare  with  figure  285. 


Fig.  287. — Colles'  fracture,  radial  side.     Marked  crease  at  base  of  thumb.     Dorsal  and  palmar 

prominences. 


Fig.  28S.— Colles'  fracture,  ulnar  side.     Absence  of  ulna  on  the  dorsum  of  the  wrist  ;  presence 
anteriorly.     Marked  crease  in  front  of  displaced  ulna.     Dorsal  prominence  marked. 


and  flexion,  extension,  abduction,  and  adduction  of  the  hand 
should  be  carefully  performed.  These  simple  observations 
quickly  made  upon  the  normal  wrist  enable  one  to  establish  a 
standard  for  comparison  with  the  injured  wrist.      In   ever}-  case 


222       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

in  which  there  is  a  question  of  fracture  the  examination  should 
be  made  by  means  of  an  anesthetic  (see  Fig.  283).  If  for  suf- 
ficient reason  complete  anesthesia  is  contraindicated,  primary  an- 
esthesia will  prove  to  be  sufficient.  In  the  larger  proportion 
of  cases  of  Colles'  fracture  primary  anesthesia  will  be  satisfactory 
for  both  the  examination  and  the  first  dressing  of  the  fracture. 

Symptoms. — In  Colles'  fracture  the  wrist  appears  unnatural. 
The  thenar  eminence  of  the  thumb  is  higher,  nearer  to  the  wrist 
than  usual,  as  compared  with  the  hypothenar  eminence  (see  Fig. 


Fig.  2S9.  —  Colles' 
fracture,  anterior  bulg- 
ing of  flexor  tendons  ; 
absence  of  dorsal  prom- 
inence of  bead  of  ulna. 


Fig.  290. — Colles'  fracture. 
The  dorsal  prominence  is  not 
uncommonly  seen  after  recov- 
ery from  fracture  of  the  radius 
when  tbe  displaced  bones  bave 
been  but  partially  reduced. 
Slight  lateral  delonnity. 


Fig.  291. — Colles'  fracture. 
Hand  carried  to  radial  side. 
Prominent  ulna  anteriorly. 
Thenar  eminence  lower  than 
normal. 


291).  Anteroposterior  and  lateral  deformities  are  apparent  to  a 
greater  or  less  degree.  It  is  said  that  at  times  an  anterior  dis- 
placement of  the  lower  fragment  occurs,  the  reverse  of  the  ordi- 
nary displacement.      It  is  unusual  (see  Fig.  284). 

The  anteroposterior  deformity  is  caused  by  the  projection  of 
the  lower  end  of  the  upper  fragment  into  the  palmar  surface  of 
the  wrist,  pushing  the  flexor  tendons  forward  (see  Fig.  285), 
and  by  the  projection  of  the  upper  end  of  the  lower  fragment 
toward  the  dorsal  surface  of  the  wrist,   pushing  the    extensor 


COLLES      FRACTURE SYMP'i  <  IMS 


223 


tendons  backward.  Impaction  of  the  radial  fragments  may  be 
another  factor  in  the  production  of  the  deformity.  This  deform- 
ity is  spoken  of  by  the  older  writers  as  the  silver-fork  deformity. 
The  reason  is  obvious  (see  Figs.  286,  287,  288,  289,  290). 

The  lateral  deformity  (see  Fig.  291)  is  caused  by  several  fac- 
tors :  the  impaction  of  the  radial  fracture,  lateral  displacement  of 
the  lower  fragment,  and  by  rupture  of  the   inferior    radio-ulnar 


Fig.  292. — A  form  of  comminution   in   Colles'  fracture.     Left  wrist   from   back  and   below 

(diagram). 


Line  of  fracture.  — 

T-Hne. f. 

Lower  radial  fragment. ; — f — zs. 


Semilunar  bone.  -       / 

/ 
/ 


<j — L Styloid  process  of  ulna. 


Fig.  293. — Colles'  fracture.     Anteroposterior  view.     Slight  lateral  deformity.     Anterior  view 
of  figure  294  (Massachusetts  General  Hospital,  1028.     X-ray  tracing;. 


ligaments.  The  abduction  of  the  whole  hand,  the  prominence 
laterally  of  the  lower  end  of  the  ulna,  the  disappearance  of  the 
ulnar  head  from  the  dorsum  of  the  wrist,  are  to  be  noted.  Because 
of  the  displacement  of  the  radial  lower  fragment,  the  normal  rela- 
tions are  no  longer  maintained  between  the  styloid  processes  of 
the  radius  and  ulna.  There  is  a  reversal  of  relations.  The 
radial  styloid  is  higher  than  usual.  It  is  on  the  same  level  with 
or  higher  than  the  head  of  the  ulna. 


224 


FRACTURES    OF    THE    BONES    OF    THE    FOREARM 


It  is  possible  to  have  present  a  fracture  of  the  lower  end  of 
the  radius  (a  Colles'  fracture)  without  any  appreciable  alteration 
in  the  levels  of  the  styloid  processes.  The  existence  of  the 
normal  relations  of  the  styloids  does  not  preclude  the  presence 
of  a  fracture. 

Lower  radial  fragment  rotated. 
Scaphoid. 


First  metacarpal. 


Carpus. 


Styloid  of  radius. 


Fig.  294. — Colies'  fracture.     Lateral  view  of  figure  293.     Rotation  of  lower  fragment  on  trans 
verse  axis.     Cause  of  dorsal  and  palmar  deformity  evident  (X-ray  tracing). 


Lower  fragment  of  _  ' 

radius. 

I 


Fig.   295. — Simple   transverse   Colles'    fracture.      Anteroposterior   view.     Lateral   deformity 

(X-ray  tracing). 


1  )irect  pressure  over  the  broken  bones  elicits  pain,  but  crepitus 
is  often  undetected  until  the  patient  is  examined  with  the  aid  of 
an  anesthetic.  A  transverse  rid^e  is  sometimes  present  on  the 
posterior  and  external  surface  of  the  radius,  corresponding  to  the 
line    of  fracture.      In   certain  cases  of  Colics'  fracture   the  wrist 


o  H 


226 


FRACTURES  OF  THE  BOXES  OF  THE  FOREARM 


may  not  appear  very  unnatural.  There  may  be  scarcely  any 
deformity.  The  normal  relation  may  be  nearly  preserved.  If 
there  is  little  displacement  of  the  fragments,  it  may  be  difficult  to 


Radius. 


Ulna. 


Line  of  fracture. 


Fig.  298. — Simple  transverse  Colles'  fracture.     Lateral  view.     Same  as  figure  295  (Massachu- 
setts General  Hospital). 


1        V, 


Styloid  process. f q 

/ 
I 


Radius. 


Fig.  299-  Colles'    Fracture.     Fracture  of  styloid  of  ulna.     A  T-fracture  into  the  wrist-joint. 
Much  lateral  deformity  (X-ray  tracing). 


determine  the  existence  of  fracture.  An  appreciation  of  slight 
differences  from  the  normal  will,  under  these  circumstances, 
prove  of  great  value.  The  Rontgen  ray  will  be  of  service  in 
this  connection. 


COLLES      FRACTURE DIFFERENTIAL    DIAGNOSIS 


227 


After  injury  to  the  wrist  one  must  consider  in  the  differential 
diagnosis — 

A  sprain  of  the  wrist,  Fracture  of  the  shaft  of  one  or  both  bones 

Contusion  of  the  bones  near  the  wrist,  low  down, 

Dislocation  of  the  wrist  backward.  Separation  of  the  lower  radial  epiphysis. 

A  sprain  of  the  wrist  is  rather  unusual.  There  very  often 
exists  in  so-called  sprains  a  definite  anatomical  lesion  of  bone. 
The  deformity  due  to  the  distention  of  the  synovial  sac  with  fluid 


__ Ulna. 

f~y-_ Displaced  styloid  process 

(-^  of  ulna. 


Fig.  300. — Colles'  fracture  with  fracture  of  base  of  ulnar  styloid  ;  outward  displacement 
of  styloid  fragment.  Shaft  of  radius  driven  into  the  lower  fragment  (Massachusetts  General 
Hospital,  1173.     X-ray  tracing). 


Fig.  301. — Radial   fracture  upward  and  outward  (Massachusetts  General  Hospital,  1126. 

X-ray  tracing). 


is  conspicuous  over  the  back  of  the  wrist-joint  and,  therefore,  near 
the  hand.  There  is  tenderness  upon  pressure  over  the  synovial 
membrane  anteroposteriorly.  There  is  little  or  no  tenderness 
over  the  radius  upon  deep  pressure.  There  is  an  absence  of  the 
positive  signs  of  fracture.  It  is  not  an  uncommon  experience 
to  find  an  injury  to  the  lower  end  of  the  radius  presenting  no 
positive  fracture  signs,  which  is  proved  by  the  Rontgen  ray  to 
be  a  break  of  the  lower  end  of  the  radius.  A  lesion  somewhat 
resembling   that   shown  in  figure   292,  the  bone  being  cracked 


'28 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


along  those  same  lines  but  without  displacement,  is  found  to 
exist.  Many  of  these  obscure  lesions  are  passed  over  as  sprains 
of  the  wrist.  Any  injury  to  the  wrist,  no  matter  how  trivial, 
should  be  regarded  with  suspicion  until  there  is  absolute  proof 
that  fracture  is  absent. 

A    Contusion   of   One  or  Both   Bones    near   the  Wrist-joint : 


Fig.  302  — Fracture  of  inner  edge  of  the  radius  1  X-ray  tracing) 


I  i.^-  3".;- — Fracture  of  radial  st\  loid  (Massachusetts  1  retieral  Hospital,  1 2^2.    X-ray  tracing 


Tenderness  is  localized.      Fracture    signs  are  all  absent.     The 
Rontgen  ray  will  assist  in  determining  this  diagnosis. 

Dislocation  of  the  wrist  backward  is  rare.  The  posterior 
prominence  is  lower  down  on  the  wrist  than  in  Colles'  fracture. 
The  upper  surface  of  the  displaced  carpus  can  be  felt.  The  rela- 
tion of  the  two  styloids  is  preserved.      The  deformity  disappears 


COLLES      FRACTURE DIFFERENTIA!.    DIAGNOSIS 


229 


and  does  not  tend  to  reappear  when  traction  is  made  on  the  hand 
and  pressure  is  made  over  the  dorsal  prominence. 

Fracture  of  the  shaft  (see  Fig.  305)  of  one  or  both  bones 
low  down  may  simulate  the  anteroposterior  deformity  of  Colics' 
fracture,  but  an  absence  of  other  positive  signs   is  important. 


n~ 


Radial  epiphysis,  outer 
fragment. 


-\&^ 


I  Radial  epiphysis,  inner 

: fragment. 

Q--t —   Displaced  styloid  pro- 
cess of  ulna. 
—  Ulnar  epiphyseal  line. 


Fig.  304. — Fracture  of  the  epiphysis  of  the  lower  end  of  the  radius  and  of  the  styloid  process 
of  ulna  (Massachusetts  General  Hospital,  7r2.     X-ray  tracing). 


fig.  305. — Colles'  fracture,  with  fracture  at  lower  end  of  ulna  (X-ray  tracing). 


The  Rontgen  ray  determines  the  exact  seat  of  the  lesion.  Ab- 
normal mobility  and  crepitus  are  readily  obtained  without  the 
administration  of  an  anesthetic. 

A    Separation    of    the    Lower     Epiphysis    of    the     Radius  : 
The   lower  epiphysis    of  the  radius   unites  with  the  shaft   about 


Fig.  306. — Case:  Adult.     Very  great   comminution  of  lower  end  of  the  radius.     Extremely 
difficult  to  mold  fragments  into  good  positions.     Note  abduction  of  hand. 


COLLES     FRACTURE ASSOCIATED    LESIONS 


231 


the  twentieth  year.  The  radius  increases  in  length  chiefly 
through  growth  from  its  lower  epiphysis.  This  lesion  occurs 
much  more  commonly  than  has  hitherto  been  supposed.  It 
is  usually  classed  as  a  Colles'  fracture,  no  very  careful  exam- 
ination being  made.  There  is  usually  less  deformity  than  is 
found  in  most  Colles'  fractures,  and  it  is  nearer  the  hand.      The 


Fig.  307. — Reduction  of  Colles'  fracture.     Note  position  of  hands  in  forcibly  hyperextending 
the  lower  fragment ;    breaking  up  impaction. 


Fig. 


308. — Reduction  of  Colles'  fracture.    Note  grasp  upon  forearm  and  the  lower  fragment  of 
the  radius,  traction  and  countertraction  being  made  ;  breaking  up  the  impaction. 


creptius  is  soft  and  cartilaginous,  and  easily  obtained  without  an 
anesthetic.  The  treatment  of  separation  of  the  lower  radial 
epiphysis  is  similar  to  that  of  a  Colles'  fracture.  A  fracture  of 
the  lower  radial  epiphysis  is  occasionally  seen  ;  it  is,  however,  a 
rare  lesion  (see  Fig.  304). 

Associated  with  every  Colles'   fracture  there  may  be   one  or 
more  of  the  following  lesions  :     A  fracture  through  the   lower 


2  $2  FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

end  of  the  ulna,  which  is  rather  rare  (see  Fig.  305).  A  fracture 
of  the  styloid  process  of  the  ulna,  which  occurs  in  about  fifty  to 
sixty-five  per  cent,  of  all  cases  (see  Fig.  300).  A  rupture  of  the 
interarticular  triangular  fibrocartilage  at  its  insertion  into  the  base 
of  the  styloid  process  of  the  ulna.  This  is  probably  quite  com- 
mon, and  accounts  in  part  for  the  broadening  of  the  wrist-joint. 
A  perforation  of  the  skin  by  the  lower  end  of  either  the  ulna  or 
the  shaft  of  the  radius,  making  an  open  fracture.  A  fracture  of 
the  scaphoid  bone,  although  occurring  often  alone,  is  not  very 
commonly  associated  with  Colles'  fracture.  A  sprain  of  the 
hand,  wrist,  forearm,  elbow,  or  shoulder  may  occur.  It  is  wise 
to  examine  the  whole   upper  extremity,  particularly  a  few  days 


Fig.  309. — Reduction  of  Colles'  fracture.  Note  position  of  the  thumbs  and  fingers. 
Lower  fragment  is  pushed  into  place  while  counterpressure  is  made  by  the  fingers  upon  the 
upper  fragment. 


after  the  accident,  as  it  is  at  this  time  that  sprains  associated 
with  fracture  are  likely  to  be  felt. 

Treatment. — The  ordinary  uncomplicated  fracture  is  here 
under  consideration.  Reduction  should  be  accomplished  as 
soon  as  possible.  Complete  reduction  can  not  be  made  satis- 
factorily without  the  administration  of  an  anesthetic,  either  to 
complete  or  partial  anesthesia.  Very  great  force  is  needed  to 
accomplish  satisfactory  reduction  of  impacted  fractures  of  the 
radius.  It  is  because  of  the  use  of  too  little  force  that  often  a 
slight  bony  deformity  remains  after  union  has  taken  place. 

A  Method  of  Reduction. — Grasp  with  the  thumbs  and  fore- 
fingers of  the  two  hands  the  upper  and  lower  fragments.  Free 
the  lower  fragment  completely  from   the  upper  by  pressure  and 


COLLES      FRACTURE — TREATMENT  233 

traction  backward  and  forward  and  laterally  upon  the  lower  frag- 
ment, using  all  the  force  that  is  needed  (see  Figs.  307,  308). 
The  lower  fragment  may  then  be  forced  into  position  by  pressure 
of  the  two  thumbs  upon  the  dorsum  of  the  wrist  (see  Fig.  309J. 
When  reduction  is  completed,  the   hand   should  be  allowed  to 


310. — Fracture  of  radius  near  wrist.     Method  of  applying  the  posterior  splint  and  dorsal 
pad  in  displacement  of  lower  fragment  backward. 


Fig.  311. — Fracture  of  radius  near  wrist.  Method  of  applyinganterior  splint  and  pad  and 
of  holding  the  two  splints  and  arm  for  the  application  of  straps.  Anterior  splint  is  cut  out 
below  the  thenar  eminence. 


rest  naturally  without  support  to  determine  whether  there  is  a 
recurrence  of  the  deformity.  If  there  is  no  recurrence  of  the  de- 
formity, the  fracture  may  be  fixed.  If  there  is  recurrence  of  the 
deformity,  notice  should  be  taken  of  the  direction  of  the  displace- 
ment of  the  lower  fragment,  that  proper  pads  may  be  applied  to 
hold  it  in  position.      A  pad  of  compress  cloth  placed  on  the  dor- 


234 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


sum  of  the  wrist  over  the  lower  fragment  will  easily  hold  it  if  or- 
dinarily displaced.  A  knowledge  of  the  direction  of  the  displace- 
ment of  the  lower  fragment  will  suggest  the  prevention  of  the 
recurrence  of  the  deformity.  The  Rontgen  ray  is  making  pos- 
sible a  more  intelligent  treatment  of  this  fracture  of  the  radius. 
The  bone  is  so  nearly  subcutaneous  that  one  can  take  advantage 
of  an  accurate   knowledge  of  the    line    or  lines    of  fracture    in 


Fig.  312.— Fracture  of  the  forearm  near  the  wrist-joint.  Anterior  and  posterior  splints. 
Straps  are  taut.  Note  length  of  splints,  the  position  of  the  three  straps,  and  the  cutting  out 
of  the  anterior  splint  to  clear  the  thenar  eminence. 


Fig.  313.— Fracture  of  the  forearm  near  the  wrist-joint.  Notice  wrinkles  in  the  straps. 
The  straps  are  loose  from  the-  pressure  of  the  two  splints  together.  Thus  is  illustrated  the  fact 
that  the  straps  retain  splints  in  position  without  exerting  much  pressure. 


attempting  reduction  of  the  malposition.  Intelligently  applied 
force  can  now  be  used  in  each  fracture  instead  of  the  hitherto 
blind  routine  manipulations.  Thus,  less  injury  is  done  in  set- 
ting the  fracture,  and  better  anatomical  results  are  obtained. 

It  is  well  to  restore,  if  possible,  the  prominence  of  the  lower 
end  of  the  ulna  at  the  back  of  the  wrist.  Usually,  after  a  Colles' 
fracture  has  healed  and  functional   usefulness   is   restored   to  the 


COLLES'    FRACTURE TREATMENT  235 

wrist  and  hand,  the  ulna  will  be  found  to  have  slumped  forward 
— to  have  disappeared  from  the  dorsum  of  the  wrist.  This  can 
be  corrected  somewhat  by  padding  the  ulna  anteriorly  and  by 
completely  correcting  the  radial  deformity  and  strongly  adduct- 
ino-  the  hand. 


Fig.  314. — Posterior  splint  padded  with  two  thicknesses  of  sheet  wadding.   Two  straps.    Note 
length  of  splint  and  position  of  straps. 


Fig.  315. — Posterior  splint,  three  straps,  and  pad  at  the  seat  of  fracture.     Note  comfortable 
position  of  forearm  and  hand. 


Fig.  316. — Completed  dressing,  similar  to  figures  314,  315.     The  bandage  is  applied  evenly 

and  uniformly. 

Retentive  Apparatus. — The  simplest  splint  is  the  best.  If 
there  is  considerable  swelling  about  the  seat  of  fracture  in  a 
rather  muscular  and  large  arm,  it  is  best  to  use  the  following 
apparatus  :  Two  pieces  of  splint-wood,  one  for  the  back  and  the 


236       FRACTURES  OF  THE  BOXES  OF  THE  FOREARM 

other  for  the  front  of  the  forearm,  are  provided.  The  back  or 
posterior  splint  should  extend  from  the  heads  of  the  metacarpal 
bones  to  a  little  above  the  middle  of  the  forearm  (see  Fig.  310). 
The  front  or  anterior  splint  should  extend  from  the  heads  of  the 
metacarpal  bones  to  a  little  above  the  middle  of  the  forearm  (see 
Fig.  311).  These  splints  are  padded  evenly  and  smoothly  with 
sheet  wadding,  retentive  pads  at  the  seat  of  the  fracture  being  used 
as  needed.  The  hand  and  forearm  are  held  in  semipronation.  The 
hand  is  adducted.  The  dorsal  splint  is  applied  and  held  in  posi- 
tion. The  anterior  splint  is  then  applied  with  the  pads,  and  all  are 
held  in  position  by  adhesive-plaster  straps.  The  arm  and  splints 
are  covered  with  a  bandage.  Direct  pressure  should  be  avoided 
over  the  head  and  styloid  process  of  the  ulna  posteriorly,  in  order 


Fig.  .517. — Hand  and  fingers  extended.  Dorsal  surface  of  forearm  and  hand  practically 
straight  and  in  the  same  plane.  The  anterior  surface  of  the  forearm  and  hand  are  rounded 
and  irregular  surfaces. 

to  minimize  the  disappearance  of  the  bone  from  the  dorsum  of  the 
wrist.  A  pad  placed  anteriorly  and  laterally  over  the  lower  end 
of  the  ulna  is  often  useful  in  reducing  the  ulnar  head  and  styloid. 
The  adhesive-plaster  straps  should  be  snugly  but  loosely  applied. 
The}-  are  intended  simply  to  retain  the  splints  in  position  (see 
Fig.  312J.  After  their  application,  pressing  the  two  splints  to- 
gether should  show  that  there  is  considerable  slack  in  the  straps 
(see  Fig.  313);  a  spring  should  exist  between  the  splints.  The 
necessary  pressure  on  the  splints  should  be  secured  by  the  band- 
age. The  fingers  are  allowed  to  be  free  and  movable.  The  arm 
is  held  in  a  sling.  The  sling  should  be  so  adjusted  as  to  receive 
the  whole  weight  of  the  arm,  the  hand  lying  free  from  the  up- 
ward pressure  of  the  sling.  The  sling  should  be  applied  with 
the  ends  crossed  in  front  of  the  neck. 


COLLES   FRACTURE TREATM  EXT 


237 


At  the  end  of  the  first  week  in  most  cases,  in  place  of  the  two 
anteroposterior  splints,  it  will  be  wise  to  use  one  posterior  splint 
only  and  an  anterior  pad  over  the  seat  of  fracture.  The  poste- 
rior splint  is  applied  evenly  padded,  and  if  necessary,  a  small  pad 
is  placed  over  the  dorsum  of  the  lower  fragment.  The  splint  is 
held  in  place  by  two  adhesive-plaster  straps — one  at  the  upper 
end  of  the  splint  around  the  forearm,  the  other  around  the  meta- 
carpal bones  at  the  lower  end  of  the  splint  (see  Fig.  314).  The 
fracture  should  be  held  securely  by  a  third  strip  of  adhesive 
plaster  at  the  seat  of  fracture  over  a  compress-cloth  pad,  which 
fills  up  the  anterior  hollow  of  the  radius  (see  Fig.  315).  This  pad 
holds  the  fragments  securely.  A  roller  bandage  gives  even  com- 
pression and  support  to  the  whole  arm  (see  Fig.  316). 

The  posterior  surfaces  of  the  forearm,  wrist,  and  hand  in  the 
extended  position  are  practically  in  one  plane   (see   Fig.    317); 


Fig.  31S. — Anterior  and  posterior  splint?.     Diagram  of  pad  to  fit  the  radial  arch. 


hence,  the  reasonableness  of  the  use  of  the  posterior  splint.  The 
arm  lies  naturally  upon  it.  The  anterior  surface  only  requires 
accurate  padding.  The  difficult}-  in  applying  an  anterior  splint 
accurately  to  the  forearm  and  wrist  is  rendered  clear  by  the 
illustration.  The  front  of  the  forearm  and  wrist  is  a  rounded  and 
uneven  surface  (see  Fig.  317).  In  order  accurately  to  control 
the  bone  by  a  splint  applied  to  the  anterior  surface  of  the  fore- 
arm, the  padding  must  be  applied  with  greater  care  than  is  ordi- 
narily exercised.  Xo  splint  is  manufactured  that  fits  the  wrist 
accurately.  If  the  surgeon  depends  upon  manufactured  and 
molded  splints,  he  is  in  very  great  danger  of  neglecting  the  frac- 
ture (see  Fig.  318).  It  is  wiser  for  the  surgeon  to  use  simple 
splints,  and  to  hold  the  fracture  reduced  by  personally  applied 
pads  and  straps. 


238 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


Until  the  time  of  union  the  arm  should  always  be  comfortable. 
The  patient  should  be  seen,  if  convenient,  within  the  first  twenty- 
four  hours  of  the  application  of  the  splint.  Swelling  may  occur 
after  the  splints  are  applied,  causing  blueness  or  swelling  of 
the  fingers.  The  bandage  may  need  reapplying  to  relieve  this 
increase  of  pressure.  With  the  subsidence  of  the  primary 
swelling  the  bandage  naturally  loosens  and  will  require  tighten- 
ing.     It  is  rare  that  the  straps  and  padding  will  need  more  than 


Fig.  319. — Colles'  fracture.     Position  of  short  dorsal  splint  of  wood  and  palmar  pad  of  com- 
press cloth.     Note  method  of  holding  before  the  application  of  the  strap. 


Fig.  320. — Colles' fracture.    Short  dorsal  splint  and  palmar  pad  held  in  position  by  adhesive- 
plaster  strap. 


slight  readjustment  during  the  first  week  of  treatment.  At  least 
every  three  days  the  pads  should  be  removed  with  great  care, 
and  the  arm  carefully  inspected.  The  alinement  of  the  fragments 
is  maintained  by  readjustment  of  the  pads. 

Gentle  massage  should  be  instituted  to  the  fingers,  hand, 
wrist,  and  forearm  during  the  second  week.  Passive  and  active 
movements  of  the  fingers  and  wrist  are  to  be  made  through 
the  second  week.      During  the  second  or  third  week  it  will  lie 


COLLES   FRACTURE TREATMENT 


239 


possible  to  shorten  the  dorsal  splint  and  also  to  increase  the 
amount  of  passive  and  active  motion.  At  the  end  of  the  second 
or  third  week  the  union  will  be  found  to  be  firm.     During-  the 


Fig.  321. — Colles'  fracture.  Cravat  sling 
holding  wrist  improperly.  Hand  pro- 
nated. 


Fig.  322.— Colles'  fracture.  Cravat  sling 
holding  wrist  properly.  Hand  semisupin- 
ated.  Wrist  resting  upon  ulnar  side  with 
hand  unsupported. 


mm 

1      M 

m- 

I 

i^*--- 

Fig.  323.— Right  Colles'  fracture  in  an  old  woman.  Splints  applied  for  five  weeks  without 
removal.  Note  deformity  and  flattening  of  hand  and  forearm.  The  fingers  and  wrist  are 
stiff  and  swollen.     Left  hand   is  normal. 


third  or  fourth  week  the  splint  may  be  removed  and  the  wrist  be 
supported  by  a  wooden  dorsal  pad  (see  Figs.  319,  320)  two  inches 
long  and  the  width  of  the  wrist,  and  by  a  palmar  radial  pad  of 
compress   cloth  and  strips  of  adhesive  plaster  about  two  inches 


24O  FRACTURES    OF    THE    BOiNES    OF    THE    FOREARM 

wide.  The  middle  of  the  plaster  should  come  at  the  line 
of  the  break  in  the  bone.  After  the  fourth  week  all  padding- 
may  be  removed,  and  the  wrist  supported  by  a  simple  bandage. 
The  fingers  and  hand  may  be  used  at  this  time.  After  the 
removal  of  the  splint  and  while  the  arm  is  carried  in  a  sling 
great  care  must  be  exercised  lest  lateral  deformity  result  through 
an  improper  adjustment  of  the  sling  (see  Fig.  321).  The 
forearm  should  rest  in  the  sling  upon  the  ulnar  side,  and  the 
hand,  being  unsupported,  should  be  slightly  adducted  (see  Fig. 
322). 

The  treatment  of  a  "  reversed  Colles'  "  fracture  (see  Fig.  284) 
will  differ  from  the  treatment  of  the  ordinary  fracture  only  in  the 
method  of  reduction  and  in  the  position  of  the  retaining  pads. 
An  anterior  (palmar)  pad  will  be  needed  over  the  lower  fragment 
and  a  posterior  (dorsal)  pad  over  the  shaft  of  the  radius. 

Prognosis  and  Result. — The  swelling  about  the  fracture  in 
elderly  people  will  persist  longer  than  in  the  young.  A  func- 
tionally useful  wrist-joint  and  hand  should  follow  a  simple  un- 
complicated Colles'  fracture  in  healthy  young  adults.  For  some 
weeks  tenderness  may  exist  over  the  styloid  of  the  ulna.  Limi- 
tation of  pronation  and  supination  may  persist  for  some  time, 
disappearing,  after  several  months,  more  or  less  completely. 
Supination  is  the  last  movement  to  be  recovered.  Limitation  of 
movement  at  the  wrist  and  in  the  fingers  is  not  incompatible  with 
a  useful  wrist-joint.  Bony  union  is  rapid — within  three  weeks. 
Care  must  be  exercised  lest  in  the  early  removal  of  support  the 
soft  callus  is  molded,  by  the  ordinary  movements  of  the  wrists 
and  hand,  into  some  permanent  deformity. 

The  destruction  of  parts  of  the  lower  fragment  of  the  radius 
may  have  been  so  complete  that  it  is  impossible  to  restore  the 
wrist  to  its  normal  shape,  and  some  bony  deformity  will  remain 
permanently  (sec  X-ray  plate,  p.  230).  Bony  deformity  is  not 
incompatible  with  a  functionally  useful  arm.  In  man}'  instances 
it  is  impossible  wholly  to  prevent  a  slumping  forward  of  the 
head  ol  the  ulna  and  its  corresponding  disappearance  from  the 
back  of  the  wrist.  Complete  reduction  of  the  radial  deformity 
together  with  a  frequently  re-adjusted  pad  upon  the  palmar 
surface   of  the  wrist  over  the   slumping   ulna-head  are  the  best 


COLLES  FRACTURE PROGNOSIS  24 1 

methods  for  preventing  the  disappearance  of  the  ulna  from  the 
dorsum  of  the  wrist.  Some  slight  widening  of  the  wrist  will 
remain  after  most  Colles'  fractures.  The  changes  in  the  tendon 
sheaths  about  the  fracture,  the  periarticular  adhesions  that  form, 
especially  in  elderly  people,  cause  much  more  hindrance  to 
recovery  of  function  than  do  the  bony  alterations  (see  Fig.  323). 
Pearly  and  persistent  massage  and  passive  motion  will  prevent 
these  changes  from  becoming  permanently  troublesome.  Old 
people  are  liable  to  have  considerable  difficulty  in  regaining  the 
movements  of  the  fingers,  on  account  of  adhesions  within  and 
without  the  tendon  sheaths.  The  continued  use  of  the  hot-air 
treatment  is  of  value  in  restoring  mobility  to  the  wrist  and 
fingers. 

Colles'  fractures  that  have  bony  union  with  marked  deformity 
should  be  corrected  by  osteotomy,  if  the  wrist  is  functionally 
impaired.  Colles'  fractures  two  or  three  weeks  old  may  be  re- 
fractured  manually,  if  necessary,  to  correct  existing  deformity. 
The  ease  of  refracture  and  the  limits  in  time  within  which  it  is 
possible  will  vary  with  individual  cases.  The  more  nearly  the 
deformity  in  Colles'  fracture  is  corrected,  the  milder  will  be  the 
subsequent  pain  about  the  wrist. 


16 


CHAPTER   XI 

FRACTURES  OF  THE  CARPUS,  METACARPUS,  AND 

PHALANGES 

FRACTURE  OF  THE  CARPUS 
Simple  fracture  of  the  carpal  bones  is  unusual.  It  is  as- 
sociated with  other  injuries.  It  is  not  uncommonly  seen  in 
crushes  resulting  in  open  fracture.  The  scaphoid  is  found  frac- 
tured in  certain  Colles'  fractures  and  in  falls  upon  the  out- 
stretched hand.      There  are  many  cases  of  painful  wrist,  "  rheu- 


—  Scaphoid. 


Fig.  324.— Normal  wrist.     No  injury  (X-ray  tracing). 


matism"  about  the  wrist,  weak  wrist,  and  sprained  wrist  that 
arc  instances  of  unrecognized  fracture  of  the  scaphoid  bone. 
The  persistence  of  the  difficulty  necessitates  a  physician's  exami- 
nation. In  these  cases  a  Rontgen-ray  examination  will  reveal 
the   true   nature   of  the   lesion.      After  fracture   of  the  scaphoid 

242 


FRACTURE  OF  THE  CARPUS 


243 


bone  persistent,  painful  limitation  of  extension  at  the  wrist  is  not 
at  all  uncommon.  The  os  magnum  is  sometimes  fractured  by 
falls  upon  the  hand. 

Treatment.  —  If  there  is  displacement,  immediate  pressure  and 
counterpressure,  associated  with   extension   and   flexion   of  the 


Scaphoid  fragment. 

Scaphoid  fragment. 

Radial  fissure. 


Fig.  325. — Case  :  Fracture  of  the  scaphoid  and  fissure  of  radius  (X-ray  tracing)  (Balch). 


Crack  of  ulna 
Epiphyseal  line.  — 


Scaphoid  fragment. 
Scaphoid  fragment. 


Epiphyseal   line   of 
radius. 


Fig.  326. — Fracture  of  the  scaphoid.     Lesion  of  epiphysis  of  ulna  (X-ray  tracing)  (Balch). 


wrist-joint,  under  an  anesthetic  will  usually  reduce  the  displace- 
ment. Immobilization  of  the  wrist-joint  should  be  secured  by 
means  of  a  dorsal  splint  extending  from  above  the  middle  of  the 
forearm  to  the  heads  of  the  metacarpal  bones  (see  Fig.  314).  It 
should  be  retained  by  two  adhesive-plaster  straps.      Sheet  wad- 


244   FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

ding  and  gauze  roller  bandages  are  then  carefully  applied  to  the 
arm  the  whole  length  of  the  splint  (see  Fig.  316). 

With  the  splint  in  position  gentle  massage  to  the  wrist  and 
forearm  after  the  first  week  will  hasten  healing.      Gentle  passive 


Fig.  327. — Fracture  of  the  scaphoid.     The  two  fragments  are  seen  near  the  styloid  of  the 
radius  (X-ray  tracing)  (Balch). 


Scaphoid  fragment. N t-  ? 

Scaphoid  fragment 


Fig.  328. — Case  :  Fracture  of  the  scaphoid  (X-ray  tracing). 


motion  with  more  vigorous  massage  will  be  indicated  at  the  end 
of  two  weeks.  At  the  end  of  three  or  four  weeks  all  support 
save  a  roller  bandage  may  be  omitted.  Stiffness  will  persist 
after  this  injury,  especially  in  elderly  people  (see  Figs.  324—328 
inclusive). 


SYMPTOMS 


245 


FRACTURE  OF  THE  METACARPAL  BONES 
The  third  and  fourth  metacarpal   bones  arc   the    ones    most 
commonly  broken.      The  fracture  is   due  to   a  blow    upon   the 
knuckles  (see  Fig.  329). 

Symptoms. — The  deformity  is  characteristic.  The  very  con- 
siderable swelling  often  obscures  the  outline  of  the  bones,  but 
palpation  detects  the  lower  end  of  the  upper  fragment  in  the 
dorsum  of  the  hand,  while  the  upper  end  of  the  lower  fragment 


Fig.  329. — Metacarpus  and  phalanges 
showing  epiphyses  at  fifteen  years  (.Warren 
Museum,  specimen  537). 


Fig.  330. — Fracture  of  third  metacarpal . 
showing  dropping  of  knuckle.  Ligament- 
ous preparation. 


is  sometimes  felt  in  the  palm  of  the  hand  (see  Fig.  330).  This 
deformity  is  characterized  by  a  loss  from  the  line  of  the  knuckles 
of  that  knuckle  corresponding  to  the  fractured  metacarpal  (see 
Figs.  331,  332).  Pain  and  crepitus  are  present.  The  hand  can 
not  be  closed  tightly  on  account  of  the  swelling  and  pain. 

To  obtain  crepitus  easily  and  to  assist  in  reducing  the  fracture, 
it  is  best  to  grasp  the  finger  corresponding  to  the  fractured  meta- 
carpal with  the  whole  right  hand,  steadying  the  injured  metacar- 
pus with  the  left  hand,  and  then  to  make  steady  and  continuous 
traction  (see   Fig.  333).     The  distal  fragment  is   so  short  and 


246      FRACTURES    OF    CARPUS,    METACARPUS,    AlvD    PHALANGES 

movable  that  unless  this  device  is  used  to  steady  the  fragment  it 
will  be  difficult  to  determine  crepitus  and  to  reduce  the  fracture. 
This  fracture  heals  readily.     Occasionally,  however,  a  suppurative 


Fig.  331. — A,  Fracture  of  neck  of  fourth  metacarpal  bone.  Swe, ling  of  finger  and  knuckle. 
Knuckle  has  dropped  downward  toward  the  p  dm.  B,  Normal  hand.  Line  of  knuckles 
shown.     Contrast  with  A. 


Fig.  332. — Fracture  of  the  fourth  metacarpal  bone.  View  of  two  hands  from  behind:  A, 
Normal  line  of  knuckles.  B,  Knuckle  of  the  ring-finger  has  dropped  downward.  Deformity 
well  shown. 

process  may  complicate  recover}'  even  when  the  fracture  is  not 
an  open  one. 

Treatment. — After  reducing  the  fracture  by  traction  and  pres- 
sure as  suggested,  it  must  be  held  in  place  by  special  padding, 
for  the  deformity  tends  to  recur.  The  hand  and  forearm  are 
supported    upon    a    properly   padded   palmar    splint.      A    pad    is 


Fig.  333.— Method  of  grasping  hand  and  finger  in  examining  for  fracture  of  meta 
and  in  reducing  such  a  fracture. 


Fig-  334- — Fracture  of  the  neck  of  the  second  metacarpal.  Method  of  securing  extension. 
Note  adhesive  plaster,  rubber  tubing,  peg,  padding  to  finger,  pad  over  proximal  fragment. 
Counterextension  by  adhesive  plaster  about  wrist.     Ready  for  the  application  of  a  bandage. 


Fig.  335.— Fracture  of  the  metacarpal  of  the  index-finger.     Use  of  roller  bandage, 
of  roller  bandage.     Method  of  traction  and  countertraction. 

247 


Position 


248   FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

placed  in  the  palm  over  the  prominent  lower  end  of  the  meta- 
carpal.     Another  pad  is  placed   upon   the  dorsum  of  the  hand 


Fig.  336- — Fracture  of  the  metacarpal  of  the  index-finger.    Completion  of  traction.     Pressure 
and  counterpressure  by  thumb  on  the  dorsum  and  on  bandage  in  the  palm  of  the  hand. 


Fig.  337. — Fracture  of  the  metacarpal  ol  the  index-finger.     Completion  of  the  application  ol 
the  dressing.     Adhesive-plaster  straps  holding  hand  and  roller  bandage  in  position. 


over  the  upper  fragment.  These  pads  arc  secured  by  narrow 
strips  of  adhesive  plaster.  The  whole  is  then  bandaged.  If  after 
carefully  padding  the  two  fragments  and  immobilizing  them  the 


TREATMENT 


249 


deformity  is  reproduced,  the  fragments  slipping  by  each  other,  it 
may  be  necessary  to  make  permanent  traction  upon  the  finger 
(see  Fig.  334).  This  is  best  done  by  applying  narrow  adhesive- 
plaster  straps  to  the  sides  of  the  finger  held  in  place  by  circular 
and  oblique  straps.  The  hand  rests  upon  the  palmar  splint.  An 
adhesive-plaster  circular  band  passed  about  the  wrist  and  splint 
offers  continuous  countertraction.  If  the  band  is  carried  be- 
tween the  thumb  and  forefinger,  greater  security  is  obtained,  and 
there   is   much   less  likelihood  of  slipping  of  the  plaster.      The 


Fig-  338. — Transverse  fractures  of 
the  last  three  metacarpals  (X-ray  trac- 


ing- 339. — Oblique  fracture  of  the  third 
and  fourth  metacarpals  (Massachusetts 
General  Hospital,  1142.     X-ray  tracing). 


extension  upon  the  finger  is  obtained  by  fastening  the  extension 
strips  to  small  pieces  of  rubber  tubing,  and  carrying  the  tubing 
around  a  wooden  peg  or  screw  passed  through  a  hole  in  the 
splint. 

A  simple  contrivance  for  a  fracture  with  little  displacement  is 
the  use  of  a  roller  bandage  (see  Figs.  335—337  inclusive).  A 
roller  bandage  of  cotton  cloth  that  is  firm  and  not  easily  com- 
pressed and  of  a  size  comfortable  for  the  hand  to  grasp  is  selected. 
This  is  placed  in  the  palm  of  the  extended  hand  ;  the  fingers  and 
metacarpal  heads  are  drawn  down  firmly  over  it.      This  position 


Proximal  fragment. 


Fig.  340. —  Fracture  of  the  upper  end  of  metacarpal  bone  of  thumb.  Displaced  upper 
fragment  could  be  felt  in  the  palm  of  the  hand  (  Massachusetts  General  Hospital,  1785. 
X-ray  tracing). 


Phalangeal  epiphysis 


Normal  epiphyseal  1 
and  epiphysis. 


me ,      „•;        (      > 


Phalanx. 


"Separated  epiphysis 
second  metacarpal. 


Fig.  341. — Separation  of  the  distal  epiphysis  of  the  second  metacarpal  bone.  Displace- 
ment clinically  into  the  palm  of  the  hand.  Rare  (  Massachusetts  General  Hospital,  1765. 
X-ray  tracing). 


Fig.  342. — Fracture  «l  terminal  phalanx  of  thumb.     Anteroposterior  and  lateral  views  (X-ray 

tracings ), 

250 


TREATMENT 


251 


is  maintained  by  a  broad  strip  of  adhesive  plaster  around  the 
whole  hand.  Pads,  as  with  the  palmar  splint,  may  be  used  to 
reinforce  the  roller  bandage.  Unless  great  care  is  exercised,  this 
method  will  result  in  posterior  bowing  of  the  metacarpal  bone. 
If  there  is  an  anterior  displacement  of  either  or  both  fragments, 
this  roller-bandage  apparatus  is  very  efficient  in  maintaining  re- 
duction of  the  deformity. 

This  apparatus  should  be  carefully  inspected  each  day  during 
the  first  week,  to  be  sure  that  the  position  obtained  is  held  firmly. 


Fig.  343-  —  Fracture  of  the  finger. 
Wooden  splint  applied  to  the  palmar  sur- 
face.    Note  straps  and  length  of  splint. 


Fig.   344. — Finger  splint   of   copper   wire 
applied. 


After  three  weeks  the  splint  may  be  omitted.  Massage  during 
the  third  week  will  be  of  benefit.  Great  care  must  be  exercised 
in  the  use  of  the  hand  following  the  removal  of  the  splint  until 
the  fourth  week  is  passed,  for  deformity  may  result  (see  Figs. 
338-341  inclusive). 


FRACTURE  OF  THE  PHALANGES 
The  bones  lie  subcutaneously  ;  fractures  of  the  phalanges  are, 
accordingly,  comparatively  easy  to   detect.      Fractures  near  the 


Fig.  345  _a,  Finger  splint  of  aluminium  or  tin,  anterior  surface.     B,  Finger  splint  applied  to 
middle  finger,  three  straps.     Note  position  of  splint  in  palm  of  hand. 


Fig.  346. — Palmar  wooden  thumb  splint.    Note  shape,  pads,  straps,  position. 

252 


FRACTURE  OF  THE  PHALANGES 


25.3 


articular  surfaces  are  hard  to  detect  because  joint  crepitus  is 
deceptive.  The  so-called  base-ball  finger  may,  in  many  instances, 
be  associated  with  a  fracture  of  the  head  of  the  metacarpal  bone, 
and,  involving  the  joint,  occasion  a  slow  convalescence  (see  Fig. 
330). 

Symptoms. — Crepitus,  pain,  and  abnormal  mobility  are  pres- 
ent, and  occasionally  deformity  is  seen. 

Treatment. — It  is  important  that  the  alinement  of  the  phalanx 
be  maintained.  Rotation  of  the  lower  fragment  upon  its  long 
axis  is  especially  to  be  guarded  against.     Temporarily,  if  there  is 


Fig.  347.— Lateral  splint  of  wood  for  fracture  of  the  thumb.     Note  pad  at  the  side  of  first 
phalanx,  to  correct  lateral  deformit}-. 


much  swelling,  the  broken  finger  may  rest  upon  a  palmar  splint, 
the  two  adjoining  fingers  serving  as  lateral  splints  to  steady  it. 
The  contiguous  skin  surfaces  must  be  protected  by  strips  of 
cotton  cloth  and  a  drying  powder. 

A  single  splint  of  thin  wood,  extending  from  the  middle  ot 
the  palm  of  the  hand  to  the  finger-tip,  and  held  in  position  by 
adhesive -plaster  straps,  is  most  useful  (see  Fig.  343).  The  splint- 
wood  used  should  be  cut  thin  and  not  left  thick  and  bungling — 
half  the  thickness  of  the  wood  of  an  ordinary  cigar  box  is  about 
right.  The  splint  should  be  a  little  narrower  than  the  finger  itself. 
A  narrow  cotton  bandage  applied  over  the  finger  or  a  simple  cot  to 


254      FRACTURES    OF    CARPUS,    METACARPUS,    AND    PHALANGES 

cover  the  finger  will  be  comfortable  and  will  assist  in  immobiliza- 
tion. Ordinanr  letter-paper,  by  continued  folding,  may  be  made 
into  a  narrow  and  suitable  splint.  This  is  simple  and  efficient. 
It  should  be  held  in  place  by  a  bandage  or,  preferably,  by  a  cot. 
Ordinary  copper  wire  may  be  used,  as  shown  in  the  illustration, 
without  any  padding  (see  Fig.  344).  This  serves  as  a  proper 
protection  after  the  first  week  or  two,  and  is  not  so  clumsy  as 
other  splints.  The  aluminium  or  tin  finger  splint  is  easily  made 
and  satisfactory  (see   Fig.  345).      Any  displacement  in  this  frac- 


.— Thumb  splint:  a,  Pattern — measurements  are  in  inches  ;  d,  position  of  splint.    Note 
extension  of  thumb  (after  Goldthwaite). 


ture  may  be  easily  adjusted  by  narrow  adhesive  straps  and  small 
pads. 

Fractures  of  the  first  and  second  phalanges  of  the  thumb  may 
be  satisfactorily  treated  after  reduction  upon  a  dorsal  or  lateral 
splint  of  wood,  if  proper  padding  is  employed  (see  Figs.  346, 
347).  Frequently,  however,  the  tin  splint  fitted  to  the  cleft 
between  the  thumb  and  forefinger,  as  shown  in  the  illustration 
(Fig.  348),  will  immobilize  these  fractures  more  securely  and 
comfortably. 

Open  Fracture  of  the  Phalanges. —  This  is  usually  followed 
by  profuse  suppuration  from  necrosis  of  the  fractured  bones. 
This  fracture  is  to  be  treated  with  extreme  care,  especially 
as  regards   antisepsis.      Immobilization  should   continue  at   least 


OPEN  FRACTURE  OF  THE  PHALANGES  255 

four  weeks.  If  at  the  end  of  this  time  union  has  not  occurred, 
the  patient  may  be  given  the  option  of  continuing  the  treatment 
or  of  having  the  finger  amputated.  If  union  does  not  occur  after 
four  weeks  of  careful  treatment,  it  is  highly  improbable  that  it  will 
ever  occur.  Resection  of  the  bones  may  be  attempted  before 
amputation. 


CHAPTER  XII 
FRACTURES  OF  THE  FEMUR 

FRACTURE  OF  THE  HIP  OR  NECK  OF  THE  FEMUR 
Anatomy. — The  crest  of  the  ilium  can  be  felt  throughout  its 
entire  extent,  from  the  anterior  superior  spine  to  the  posterior 
superior  spine.  The  posterior  superior  spine  corresponds  to  the 
level  of  the  center  of  the  sacro-iliac  synchondrosis.  The  great 
trochanter  of  the  femur  is  easily  distinguished  even  in  fat  indi- 
viduals. Nelaton's  line  is  determined  by  stretching  a  tape  from  the 
anterior  superior  spine  of  the  ilium  to  the  tuberosity  of  the  ischium 
(see  Fig.  349).  The  top  of  the  great  trochanter  lies  at  or  a  little 
below  Nelaton's  line,  and  about  opposite  to  the  symphysis  pubis. 


Fie.  349. — Nelaton's  line  (dotted  line),  from   the   anterior  superior  spine  of  the  ilium  to 
the  tuberosity  of  the  ischium.     Bryant's  triangle  seen.     Distance  from  top  of  trochanter  to 

perpendicular  dropped  from  anterior  spine  (X  )  is  Bryant's  measurement.     After  fracture  this 
measurement  mav  be  less  than  normal. 


The  internal  condyle  of  the  femur  looks  in  the  same  general 
direction  as  the  head  and  neck  of  the  femur  (see  Figs.  350,  351). 
The  anterior  superior  spine  of  the  ilium  is  of  importance  because 
from  it  measurement  is  made  in  taking  the  length  of  the  legs 
after  fracture  of  the  femur.  Normally,  the  fingers  can  be  hooked 
behind  the  great  trochanter  toward  the  posterior  surface  of  the 
neck  of  the  bone.  By  this  manipulation  the  posterior  portion  of 
the  capsule  of  the  joint  can  be  felt. 

Fracture  of  the  Neck  of  the  Femur  in  Adults. — This  acci- 
dent occurs  most  frequently  in  elderly  people.      It  ordinarily  is 

256 


SYMPTOMS 


257 


associated  with  a  very  slight  injury,  such  as  a  trip  and  fall  upon 
the  floor  from  the  standing  position.  Undoubtedly,  in  many  in- 
stances the  fracture  precedes  the  fall.  It  is  often  difficult  to 
determine  the  exact  seat  of  the  lesion.  Whether  the  fracture  is 
within  or  without  the  capsule  of  the  joint  is  of  comparatively 
little  moment.  On  the  other  hand,  whether  the  fracture  is  im- 
pacted or  unimpacted  is  of  the  greatest  importance.      Fractures 


|V',// 


Fig.  350.  —  Femur,  from  front.  Note 
normal  relation  of  direction  of  head  and 
neck  to  that  of  internal  condyle. 


Fig.  351.  —  Femur,  from  outer  side. 
Note  normal  anterior  bowing  and  relation 
of  direction  of  head  and  neck  to  that  of  in- 
ternal condvle. 


of  the  base  of  the  neck  of  the  bone — that  is,  fractures  near  the 
trochanter — are  usually  impacted.  Fractures  of  the  neck  toward 
the  head  of  the  bone  are  usually  unimpacted  (see  Fig.  353). 
Impacted  fractures  unite  readily.  Unimpacted  fractures  often 
remain  ununited. 

Symptoms. — The  patient  is  unable  to  rise  from  the  ground. 
A  contusion  may  be  seen   over  the   hip  as  a  result  of  the  fall. 


258 


FRACTURES    OF    THE    FEMUR 


There  is  pain  in  the  hip  while  the  patient  is  lying  still.  This 
pain  is  increased  upon  motion  at  the  hip.  There  is  an  inability 
to  move  the  injured  leg  easily  and  painlessly.  There  is  limita- 
tion of  motion  of  the  injured  leg.  While  lying  upon  the  back 
it  is  impossible  for  the  patient  to  raise  the  heel  from  off  the  bed. 
The  foot  is  everted,  the  leg  having  rolled  outward.  The  whole 
extremity  lies  helpless  (see  Fig.  354).  There  is  a  slight  appre- 
ciable fullness  below  the  fold  of  the  groin.  This  fullness  in  the 
outer  upper  part  of  Scarpa's  triangle  corresponds  to  a  non- 
depressible  area  associated  with  fracture  of  the  neck  of  the  femur. 
Slight  shortening  of  the  leg  exists.      After  three  or  four  days 


Fig.  352. —  Upper  end  of  femur  in  a 
child:  a,  a,  Line  of  junction  of  epiphysis 
of  head  and  shaft;  b,  epiphysis  of  greater 
trochanter  ;  c,  epiphysis  of  lesser  trochan- 
ter (Warren  Museum,  specimen  334). 


Fig.  353. — Head  and  neck  of  femur  of 
adult.  The  lines  show  the  ordinary  seats 
of  fracture. 


this  shortening  may  increase  to  two  inches.  The  trochanter  is 
above  Nelaton's  line.  The  fascia  above  the  trochanter  is  relaxed 
(see  Fig.  355).  This  is  especially  noted  in  the  standing  position, 
with  the  patient  resting  the  weight  upon  the  well  leg.  If  the 
fracture  is  an  impacted  one,  crepitus  will  be  absent  upon  gentle 
manipulation,  unless  the  impaction  has  been  broken  up  by  some 
unwise  means.  If  the  fracture  is  unimpactcd,  crepitus  can  be 
detected  by  the  hand  while  traction  or  gentle  rotation  of  the  leg 
is  made.  The  foot  is  everted  whether  impaction  is  present  or 
not.  If  the  impaction  is  of  the  anterior  portion  of  the  neck, 
inversion  will  be  present  ;  if  the  impaction  is  of  the  posterior 
portion  of  the  neck,  eversion  will  be  present  (see  Figs.  356,  357). 


FRACTURE  OF  THE  HIP EXAMINATION 


259 


Impacted  eversion  can  not  be  inverted  nor  can  impacted  inver- 
sion be  everted  without  breaking  up  the  impaction.  In  these 
cases  of  marked  eversion  and  inversion  a  dislocation  of  the  hip 
must  be  excluded  if  possible. 

Examination. — A  prolonged  search  for  crepitus  and  abnor- 
mal mobility  must  never  be  attempted.  In  order  to  avoid  un- 
necessary movement  of  the  hip  and  because  inspection  and  gentle 
palpation  alone  will  so  often  decide  the  diagnosis,  it  is  wise  to 
follow  a  routine  examination. 

The  history  of  the  accident  should  be  obtained.  The  pres- 
ence and  location  of  pain  are  determined.  How  much  is  the 
functional  usefulness  of  the  leg  involved  ?  What  does  inspec- 
tion reveal  as  to  the  local  condition  and  the  position  of  the  limb  ? 


Fig.  354. —  Case:   Impacted  fracture  of  the  left  hip.     Note   helpless   attitude   of   limb;   foot 

everted. 


What  does  palpation  reveal?  How  do  the  measurements  of  the 
leg  and  the  trochanter  compare  with  similar  measurements  ot 
the  uninjured  leg?  Last, — and  to  be  avoided  if  a  diagnosis  has 
been  reached, — what  does  gentle  manipulation  show  as  to  the 
presence  of  crepitus  in  the  hip  ? 

In  order  to  make  a  systematic  examination  all  clothing,  ot 
course,  should  be  removed  from  the  patient.  He  then  should  be 
placed  upon  a  firm  and  even  surface.  A  hard  mattress,  a  table, 
or  a  comforter  spread  upon  the  floor  will  provide  the  necessary 
conditions.  An  anesthetic  is  hardly  ever  necessary  for  diag- 
nostic purposes.  If  an  anesthetic  is  employed,  the  hip  should 
be  handled  in  the  gentlest  manner  possible.  All  muscular 
spasm,  which  without  an  anesthetic  protected  the  hip  from  vio- 
lence,  is  abolished  ;  therefore,    movements   of  the   hip  are  felt 


260 


FRACTURES    OF    THE    FEMUR 


directly  by  the  bone  unprotected  by  muscular  spasm.  All  sud- 
den quick  movements  should  be  avoided.  There  is  great  danger 
that  an  impacted  fracture  of  the  hip  may  be  changed  by  rough 
handling,  especially  in  the  movement  of  rotation,  to  an  unim- 
pacted  fracture.  Palpation  of  the  neck  of  the  femur  with  the 
thumb  in  front  of,  and  the  fingers  behind,  the  great  trochanter 
will  detect  any  irregularity  or  thickening  and  tenderness  about 
the  neck  of  the  bone  (see  Fig.  365).      By  palpation  of  the  great 


Fig.  355.— Relaxation  of  the  fascia  lata  as  a  result  of  fracture  of  the  hip.     Most  obvious  at 
point  shown  by  the  arrow. 


trochanter  one  may  discover  there  the  seat  of  fracture.  Swell- 
ing, tenderness,  and  crepitus  maybe  found.  Only  gentle  strong 
traction  in  the  line  of  the  long  axis  of  the  thigh  should  be  made 
to  elicit  crepitus  and  abnormal  motion. 

Measurement. — The  absence  of  any  preexisting  injury  or  dis- 
ease of  the  hip  under  consideration  is  always  to  be  carefully 
noted.  Measurement  should  always  be  made  with  the  patient 
lying  on  the  back.  The  leg  should  be  brought  gently  along- 
side of  its  fellow,  and   steadied  by  an   assistant.      Measurement 


FRACTURE  OF  THE  HIP MEASUREMENT 


26l 


should  be  made  from  the  anterior  superior  spine  of  the  ilium  to 
the  internal  malleolus  upon  each  side  (see  Fig.  385).  If  there  is 
shortening  upon  the  injured  side,  a  fracture  with  some  displace- 
ment is  likely  to  have  occurred.  A  normal  difference  in  the 
length  of  the  lower  limbs  is,  however,  not  unusual.  It  is,  there- 
fore, necessary  to  determine  the  presence  of  asymmetry  if  it  exists, 
if  any  confidence  is  to  be  placed  in  the  measurements  of  the  legs. 
Measurements    should,    therefore,   be    made  of  the    tibia;   upon 


Fig.  356. — Fracture  of  the  hip.  Inward 
rotation  of  the  leg  because  of  impaction  of 
the  anterior  portion  of  the  neck  of  the 
bone. 


Fig.  357- — Fracture  of  the  hip.  Out- 
ward rotation  of  the  leg  because  of  impac- 
tion of  the  posterior  portion  of  the  neck  of 
the  bone. 


the  two  sides,  and  these  compared.  If  no  asymmetry  appears 
to  be  present,  any  differences  in  measurement  may  be  taken  to  be 
absolute.  If  it  is  impossible  to  bring  the  legs  parallel,  they 
must  be  placed  in  the  same  relative  positions  to  the  median  line 
of  the  body. 

Bryant's  method  of  measurement  is  simple  and  of  service  (see 
Fig.  349).  The  limbs  are  placed  symmetrically.  The  top  of  the 
trochanter  is  marked  upon  the  skin.  A  perpendicular  line  is 
dropped  from  the  anterior  superior  spine  to  the  table  upon  which 


262 


FRACTURES    OF    THE    FEMUR 


the  patient  lies.  Measurement  is  made  from  the  top  of  the 
trochanter  to  this  perpendicular  line.  If  fracture  of  the  neck  of 
the  femur  has  occurred,  and  there  is  displacement  or  shortening 
of  the  limb,  the  distance  from  the  perpendicular  to  the  top  of  the 


Fig.  358. — Old  fracture  of  femoral  neck  ; 
no  union.  Absorption  of  whole  neck  of 
bone.  The  contiguous  surfaces  of  the  frag- 
ments are  of  hard,  compact  bone.  There 
is  some  atrophy  of  the  whole  shaft  of  the 
femur  (Warren  Museum,  specimen  8075). 


Fig.  359.— Fracture  of  femoral  neck. 
Impaction  of  base  into  the  shaft,  with  down- 
ward and  inward  rotation  of  upper  frag- 
ment (Warren  Museum,  specimen  6303). 


Fig.  360. — Fracture  between  neck  and 
shaft  and  fracture  of  great  trochanter. 
Union  so  imperfect  that  fragments  separ- 
ated in  maceration  (Warren  Museum,  spe- 
cimen 1075). 


Fig.  361. — Fracture  of  the  neck  of  the 
femur  and  of  the  great  trochanter  in  sec- 
tion. Impaction  ;  union  not  firm  (Warren 
Museum,  specimen  5225). 


trochanter  will  be  less  than  a  like  measurement  on  the  uninjured 
side.  The  position  of  the  top  <>f  t he  great  trochanter  is  determined 
with  reference  to  Nelaton's  line  (see  Fig.  349).  If  the  leg  is 
rolled  outward,  dislocation  of  the  hip  forward  would  be  suspected. 


FRACTURE  OF  THE  HIP MEASUREMENT 


!63 


but  the  absence  of  the  head  of  the  bone  anteriorly  and  the 
absence  of  other  positive  signs  should  eliminate  dislocation.  If 
the  leg  is  rolled  inward,  a  dislocation  of  the  hip  upon  the  dorsum 
ilii  would  be  considered.  The  absence  of  other  positive  signs  of 
dislocation  and  the  presence  of  the  head  of  the  bone  in  the  acetab- 


Fig.  362. — Fracture  of  femoral  neck, 
unimpacted  ;  fibrous  union,  with  absorption 
of  the  neck  (Warren  Museum,  specimen 
3651). 


mmw 


Fig-  363. — Old  impacted  fracture  of  the 
hip  ;  penetration  of  the  inner  wall  of  the 
neck  into  the  head  of  the  bone;  displace- 
ment and  rotation  of  the  head  downward 
and  inward  (Warren  Museum,  specimen 
1086). 


Fig.  364. — Fracture  of  hip  ;  impaction  of  neck  of  bone  into  the  head  ;  rotation  of  head  down- 
ward and  backward  ;  view  from  behind  (Warren  Museum,  specimen  1086). 


ulum  should  convince  one  of  the  nonexistence  of  dislocation. 
In  an  elderly  person  who  presents  no  well-marked  sign  of  fracture, 
but  who  is  unable  to  use  the  limb  after  ever  so  slight  an  injury, 
a  fracture  of  the  hip  should  be  so  strongly  suspected  that,  until 
the  Rontgen  ray  proves  it  absent,  he  should  be  treated  as  if  a 
fracture  were  present. 


264 


FRACTURES    OF    THE    FEMUR 


Prognosis  and  Result. — In  the  very  aged  and  feeble  the  shock 
of  a  fracture  of  the  neck  of  the  femur  is  severe.  The  dan- 
ger to  life  in  these  cases  is  great.  An  elderly  patient  may  die 
of  shock  within  two  or  three  days,  or  within  a  week  of  hypo- 
static pneumonia,  or  he  may  live  several  weeks  and  die  of 
exhaustion  because  of  pain  and  the  enforced  confinement.  If 
the  fracture  can  be  treated  with  proper  immobilization,  union  will 
occur  in  most  cases.  The  impacted  cases  will  unite  ;  the  unim- 
pacted  cases  may  unite.  Slight  shortening  with  a  little  deformity, 
some  limitation  in  the  movements  of  the  hips,  a  limp,  but  a 
fairly  useful  limb,  are  to  be  hoped  for  (see  Fig.  366).  Chronic 
rheumatism  will  often  prevent  a  fractured  hip  from  ever  becom- 
ing useful. 

Nonunion  of  the  hip-fracture  does  not  preclude  a  useful  limb 


Fig.  365. — Method  of  palpating  the  trochanter  of  the  right  femur. 


(see  Fig.  367).  Ununited  fractures  of  the  hip  are  greatly  bene- 
fited by  proper  ambulatory  apparatus.  They  may  be  made  to 
unite  by  mechanical  means  even  several  weeks  and  months  after 
the  injury.  This  is  particularly  true  of  fractures  occurring  in 
young  adults. 

Results  after  Fracture  of  the  Hip. — Of  especial  value  in  this 
connection  are  the  conditions  existing  in  sixteen  cases  of  fracture 
of  the  hip,  many  years  after  the  accident.  These  sixteen  cases 
were  treated  at  the  Massachusetts  General  Hospital  by  gentle 
traction  and  immobilization,  for  periods  varying  from  a  few  weeks 
to  a  few  months.  The  patients  then  went  about  with  crutches. 
No  other  treatment  was  used.  Nearly  all  the  cases  were  un im- 
pacted either  primarily  or  secondarily.  At  the  time  of  the  acci- 
dent seven  cases  were   between  forty-two  and  forty-seven  years 


KKACTURK  OF  THE  HIP PROGNOSIS 


265 


old,  the  remainder — with  two  exceptions,  whose  ages  are  not 
stated — were  over  fifty  ;  three  were  over  sixty  years  old.  These 
cases  reported  for  examination  from  two  and  one-half  to  twenty- 
four  and  one-half  years  after  the  accident.  Thirteen  of  the  six- 
teen cases  have  impairment  of  the  functional  usefulness  of  the 
leg  ;  a  weakness  of  the  limb,  necessitating  a  crutch  in  many  in- 
stances ;  all  movements  at  the  hip  somewhat  restricted  ;  atrophy 
of  the  muscles  of  the  thigh,  buttock,  and  calf  of  the  leg  ;  a  de- 
cided limp,  requiring  a  cane  ,  pain  in  the  hip  extending  clown  the 


Fig.  366. — Deformity  following  an  old  frac- 
ture of  the  hip. 


Fig.  367. — Case:  Man,  forty-five  years 
old.  Fracture  of  the  neck  of  the  femur. 
Union  ligamentous,  with  displacement. 
Useful  limb  (X-ray  tracing). 


thigh  even  to  the  sole  of  the  foot ;  pain  at  night  in  the  hip  ; 
pain  in  going  up-stairs  and  in  stooping  over.  In  only  two  cases 
out  of  the  sixteen  could  it  be  said  that  the  leg  was  functionally 
useful. 

Treatment. — General  Considerations. — Fractures  of  the  hip  or 
of  the  neck  of  the  femur  demand  the  greatest  tact  in  their  man- 
agement. The  aged  respond  readily  to  care.  The  patient  should 
be  made  to  feel  as  comfortable  as  possible  while  confined  to  his 
bed.      Particular  attention  should  be  paid  to  diet  and  to  all  little 


266 


FRACTURES    OF    THE    FEMUR 


comforts.  The  discomforts  attendant  upon  immobilization  are 
often  very  great.  Let  the  days  spent  in  bed  be  made  especially 
attractive.  Be  sure  that  agreeable  friends  visit  the  patient,  see- 
ing to  it  that  they  do  not  stay  so  long  a  time  as  to  weary  him. 
Let  them  interest  him  in  the  news  of  the  day,  so  that  he  may 
feel  that  he  is  keeping  up  with  events.  Employ  a  skilled 
nurse  to  minister  to  his  wants  :    a  bright  and  cheerful   woman 


Fig.  368.— Case:  Fracture  of  the  neck  of  the  femur  (X-ray  tracing). 


nurse  is  ordinarily  better  than  a  man  nurse.  The  pulse  is  to  be 
rait  fully  watched  as  well  as  the  respiration.  A  moderate  amount 
of  alcohol  once  or  twice  a  day  with  meals  is  to  be  used.  The 
courage  of  the  aged  needs  bracing.  Bed-sores  develop  with 
surprising  rapidity.  Skilled  watchfulness  and  immediate  treat- 
ment will  often  check  the  progress  of  a  red  pressure  spot.  The 
part  exposed  to  pressure  should  be  kept  very  clean  with  soap 
and  warm  water  ;   it  should  be  bathed  with  alcohol,  thoroughly 


FRACTURE  OF  THE  HIP — TREATMENT  267 

dried,  and  well  dusted  with  powder  (starch  and  oxid  of  zinc, 
equal  parts) ;  and  the  pressure  should  be  relieved  by  proper  pads 
or  cushions.  If  the  heel  is  the  part  involved,  a  rubber  cushion 
or  a  ring  made  of  sheet  wadding  wound  with  a  bandage  may 
be  used.  A  certain  amount  of  moving  about  in  bed  should 
be  granted  to  old  people.  Asthenic  hypostatic  pneumonia 
frorri  long-continued  resting  in  one  position  is  not  uncom- 
mon. Therefore,  moving  about  a  little  in  bed,  to  the  extent  of 
sitting  upon  a  bed-rest  at  varying  angles,  is  beneficial.  Deep 
rhythmical  breathing  while  lying  flat  on  the  back  is  a  splendid 
stimulator  of  the  circulation.  In  the  case  of  a  fracture  of  the 
neck  of  the  thigh-bone  occurring  in  an  elderly  individual  treat  the 
patient  and  let  the  fracture  be  of  almost  secondary  importance. 

Treatment  of  the  Fractured  Hip. — The  patient  should  be 
placed  upon  a  comfortable,  firm,  hair  mattress.  Underneath  the 
mattress,  crossing  the  bedstead  from  side  to  side,  should  be 
placed  several  wooden  slats  about  eight  inches  apart.  These 
bed-slats  prevent  sagging  of  the  mattress  and  much  consequent 
discomfort.  Great  caution  must  be  exercised  that  no  sudden  or 
forcible  movements  of  the  hip  are  made  which  might  break  up 
the  impaction  of  the  bone  or  cause  unnecessary  pain.  The  leg 
should  be  placed  in  as  natural  a  position  in  extension  as  possible. 
The  knee  should  be  placed  upon  a  pillow.  Extension  strips  of 
adhesive  plaster  should  be  applied  to  the  leg  and  thigh  as  high 
as  the  perineum,  and  should  be  held  to  the  skin  by  a  gauze  roller 
bandage.  A  weight  of  about  five  pounds  should  be  applied  to 
the  extension  while  the  leg  is  gently  rotated  and  carefully  placed 
approximately  in  the  normal  position.  The  foot  of  the  bed 
should  be  elevated  to  the  height  of  six  inches  in  order  to  secure 
counterextension.  Long  and  heavy  sand-bags  should  be  placed 
on  each  side  of  the  leg  and  thigh  to  assist  the  light  extension 
in  affording  support  and  to  give  a  sense  of  security.  The  heel, 
as  mentioned  before,  should  be  properly  protected  from  undue 
pressure.  The  foot  should  be  kept  at  a  right  angle  with  the 
leg.  To  afford  still  greater  immobilization,  a  long  T-splint  ex- 
tending from  below  the  foot  to  the  axilla  of  the  injured  side  may 
be  applied  by  straps  about  the  leg  and  a  swathe  about  the  body 
(see  Fig.  398). 


268  FRACTURES    OF    THE    FEMUR 

After-care  of  the  Simple  Traction  Method. — The  general  care 
of  the  patient  should  be  as  outlined  previously.  He  should  be 
kept  quiet  in  bed  for  about  two  weeks.  During  the  second  week 
he  may  be  bolstered  up  on  pillows  to  the  half-sitting  position. 
Ordinarily,  the  extension  may  be  removed  during  the  third 
week.  The  patient  may  then  be  lifted  to  another  bed  or  divan 
and  be  rolled  into  an  adjoining  room.  In  this  change  the  thigh 
should  be  supported  by  sand-bags.  The  patient  may  be  up  in  a 
wheel-chair  after  the  first  six  weeks  or  two  months  with  the  knee 
straight  on  a  board  or,  if  comfortable,  flexed.  He  may  use 
crutches  and  a  high  shoe  upon  the  well  foot,  not  bearing  any 
weight  upon  the  injured  hip,  after  about  two  months  or  ten 
weeks.  He  should  not  bear  weight  upon  the  hip  even  with  the 
assistance  of  crutches  for  about  three  or  four  months.  At  the 
end  of  a  year  he  may  be  walking  with  one  cane.  The  foregoing 
is  the  course  of  an  ideal  case  treated  according  to  the  old-time 
simple  extension  or  partial  immobilization  method.  It  is  a 
matter  of  common  observation  that  many  impacted  hips  recover 
with  fairly  useful  limbs  with  this  treatment.  Impacted  hips  are 
known  to  have  recovered  with  useful  limbs  without  any  medical 
or  surgical  advice  or  treatment,  the  impacted  fracture  having 
been  thought  at  the  time  of  the  injury  to  be  a  severe  contusion 
which  would  be  all  right  in  time.  These  cases  have  occurred 
both  among  adults  and  children. 

Greater  immobilization  of  the  impacted  and  unimpacted  hip  is 
demanded  in  most  cases  than  can  be  obtained  by  the  simple 
traction  and  countertraction  previously  described.  The  simple 
method  is  far  from  ideal  :  malunion  and  nonunion  with  resulting 
disability  too  often  follow  its  use,  the  period  of  disability  is  long, 
and  the  ultimate  results  are  often  most  unsatisfactory.  Very 
refractory  individuals  will  have  to  be  left  pretty  much  to  them- 
selves. No  great  restraint  can  to  advantage  be  forced  upon 
them. 

The  Fixation  Method  of  Treatment. — In  order  to  put  the  unim- 
pacted bones  of  the  hip-joint  under  the  very  best  conditions  for 
union  to  take  place  not  only  must  the  fragments  be  approximated 
by  traction,  correction  of  eversion  or  inversion,  and  lateral  pres- 
sure  over   the   trochanter  major,   but    these   fragments   must   be 


FRACTURE    OF    TIIK 


■TREATMENT 


269 


firmly  fixed.  In  order  to  immobilize  these  fragments  absolutely 
the  body  or  pelvis  and  the  thigh  must  be  fixed.  The  simple 
method  already  described,  in  spite  of  the  fact  that  it  has  been 
used  for  many  years  in  these  cases,  does  not  immobilize.  The 
most  comfortable  and  efficient  method  of  immobilization  is  by 
the  use  of  the  Thomas  hip-splint.  The  description  which  follows 
of  the  Thomas  hip-splint  and  its  use  is  that  given  by  Ridlon. 

The  Thomas  hip-splint  secures  posterior  support  to  the  frac- 
ture, gives  fixation  without  compression  of  the  fractured  region 


Fig.   369. — Thomas'   single   hip-splint  in 
position  (Ridlon). 


Fig.  370. — Thomas'  double  hip-splint  in 
position  (Ridlon). 


except  posteriorly,  allows  the  patient  to  be  lifted  with  ease,  does 
not  interfere  with  the  groin,  favors  cleanliness,  admits  of  traction, 
can  be  applied  without  moving  the  patient  and  without  assist- 
ance, and  presents  no  difficulties  after  the  initial  application  (see 
Figs.  369,  370). 

The  splint  is  made  of  soft  iron,  and  consists  of  a  main  stem,  a 
chest-band,  a  thigh-band,  and  a  calf-band.  The  stem  is  an  inch 
and  a  quarter  wide  and  one-fourth  of  an  inch  thick,  and  in  length 
reaches  from  the  axilla  to  the  calf  of  the  leg — the  length  of  the 
lower  portion  from  the  hip-joint  to  the  calf  of  the  leg  being  equal 


2/0  FRACTURES    OF    THE    FEMUR 

to  that  from  the  axilla  to  the  hip-joint.  In  the  part  opposite  the 
buttock  two  gentle  bends  are  made,  the  lower  somewhat  back- 
ward and  the  upper  upward,  so  that  the  body  and  leg  portions 
of  the  splint  follow  parallel  lines  from  one-half  to  one  inch  apart, 
the  body  portion  being  posterior  to  the  leg  portion.  The  stouter 
the  patient,  the  more  nearly  do  these  parallel  lines  coincide,  and 
in  some  cases  the  main  stem  may  be  left  entirely  straight.  To 
the  lower  end  is  fastened,  by  one  rivet,  the  calf-band,  one-six- 
teenth by  five-eighths  of  an  inch,  and  in  length  an  inch  or  two 
less  than  the  circumference  of  the  leg  at  this  point.  The  thigh- 
band  \s  one-sixteenth  by  three-fourths  of  an  inch,  and  in  length 
an  inch  or  two  less  than  the  circumference  of  the  thigh  at  its 
largest  part  ;  it  is  riveted  to  the  main  stem  just  below  the  lower 
bend,  so  that  when  applied  to  the  patient,  it  comes  well  up  to 
the  perineum.  The  chest-band  is  three-thirty-seconds  by  one  and 
one-fourth  inches,  and  in  length  nearly  equal  to  the  circumfer- 
ence of  the  chest,  being  relatively  longer  than  the  other  bands. 
It  is  fastened  by  one  rivet  after  the  upper  end  of  the  stem  has 
been  forged  flat  and  bent  back  over  it.  This  arrangement  makes 
a  fast  joint,  and  brings  the  stem  between  the  chest-band  and  the 
skin.  ///  each  cud  of  the  chest-baud  a  round  hole  is  forged  of  at 
least  one-half  of  an  inch  in  diameter. 

Summary  of  material  and  measurements  required  in  making 
the  Thomas  splint  : 

Stem,  i  T4  inches  wide,  )/±  inch  thick,  extending  from  the 
axilla  to  the  calf  of  the  leg. 

Calf-band,  ?,s  inch  wide,  TT(T  inch  thick  ;  the  length  is  two 
inches  less  than  the  circumference  of  the  calf  of  the  leg. 

Thigh-band,  %  inch  wide,  T\T  inch  thick  ;  the  length  is  two 
inches  less  than  the  largest  circumference  of  the  thigh. 

Chest-baud,  I  )±  inches  wide,  ^.,  inch  thick  ;  the  length  to 
nearly  equal  the  circumference  of  the  chest. 

.  /  hole  is  forged  at  each  end  of  the  chest-band,  y,  inch  in 
diameter.  Any  good  blacksmith  can  make  this  splint  in  a  very 
short  time. 

The  splint  is  now  bent  to  fit  approximate!}' the  patient,  padded 
on  the  side  that  is  to  come  next  the  skin  with  a  quarter-inch 
thickness  of  felt,  care  being  taken  to  leave  no  inequalities  of  sur- 


FRACTURE    OF     THE    HIP TREATMENT  2J  \ 

face,  and  then  covered  with  basil  leather  put  on  wet  and  tightly 
drawn,  so  that  when  dry  it  will  have  shrunk  sufficiently  to  pre- 
vent the  cover  from  slipping  on  the  iron.  The  splint  is  applied 
by  opening  out  the  wings  of  the  bands  looking  to  the  uninjured 
side  of  the  patient,  and  then  slipping  them,  followed  by  the 
stem,  underneath  the  patient  from  the  injured  side  ;  the  wings 
that  were  straightened  are  bent  again  by  hand  and  readily  return 
to  their  former  curves.  A  closer  and  more  accurate  adjustment 
of  the  wings  may  be  made  by  the  use  of  wrenches  ;  these  will 
be  found  especially  serviceable  in  fitting  the  chest-band  and  in 
drawing  in  the  other  bands  when  the  patient  is  very  intolerant 
of  any  threatened  movement  or  jarring. 

"  The  splint  having  been  fitted,  if  retentive  traction  is  not 
required,  the  limb  is  bandaged  to  the  stem  from  the  calf  to  the 
upper  part  of  the  thigh,  rolling  the  bandage  in  the  direction  the 
opposite  to  the  rotary  deformity  that  may  be  present  ;  then 
shoulder-straps  are  applied  by  taking  a  couple  of  yards  of  broad 
bandage  or  a  strip  of  muslin,  looping  it  round  the  stem  where  it 
joins  the  chest-band,  then  over  the  band  and  over  the  shoulders, 
and  down  to  the  ends  of  the  chest-band.  Here  it  is  passed 
through  the  holes  and  tied  ;  then  it  is  passed  across  the  interven- 
ing space  to  the  opposite  hole  and  again  tied.  If  retentive  trac- 
tion is  desired,  the  shoulder-straps  are  omitted.  To  each  side  of 
the  limb  from  the  upper  part  of  the  thigh  after  the  limb  has  been 
pulled  down  to  the  splint  a  broad  strip  of  adhesive  plaster  is 
applied.  The  lower  ends  of  the  plaster  are  turned  outward  and 
upward  around  the  wings  of  the  calf-band,  where  they  are  fas- 
tened by  a  strip  of  plaster  passed  entirely  around  the  limb  ;  the 
whole  is  then  covered  with  a  bandage.  By  this  arrangement  the 
limb  is  pulled  upon  only  to  the  extent  of  correcting  the  actual 
shortening,  and  is  held  at  one  and  the  same  length  sleeping  or 
waking,  whether  the  muscles  relapse  or  are  spasmodically  con- 
tracted. 

"The  device  aims  to  prevent  motion  in  the  axis  of  the  limb  ; 
to  prevent  lateral  motion  by  bending  the  limb  in  any  direction  ; 
to  do  this  without  constricting  the  region  of  the  fracture  ;  and  to 
enable  the  patient  to  have  the  bed-pan  adjusted  without  pain  and 
without  disturbing  the   relation  of  the  parts.      When  the  splint 


272 


FRACTURES    OF    THE    FEMUR 


has  been  applied  and  the  patient  is  in  bed,  the  nurse  should  be 
instructed  in  certain  manceuvers.  The  bed-pan  is  adjusted  by 
passing  the  arm  under  both  limbs  or  below  the  knees  and  then 
lifting  directly  upward,  making  an  incline  of  the  whole  patient 
below  the  chest-band.  By  this  manoeuver  it  is  also  more  easy 
to  smoothe  out  wrinkles  in  the  bedding  and  change  the  sheet 
than  in  the  usual  way.      The  stem  should  be  made  to  press  upon 


Fig.  371. — Tracing  of  photograph  of  patient  (see  skiagram,  Fig.  372)  four  years  after 
fracture  of  the  left  femoral  neck,  showing  the  shortening  and  turning  out  of  the  leg  (after 
Whitman). 


different  parts  of  the  skin  by  pulling  the  skin  night  and  morning 
first  to  one  side  and  then  to  the  other.  The  patient  should  be 
inspected  daily  for  pressure  sores  by  turning  him  on  the  sound 
side.  In  orderto  turn  a  patient  upon  the  sound  side  support  the 
fractured  limb  at  the  knee  with  one  hand  and  grasp  the  chest- 
band  with  the  other  ;  the  patient  then  is  readily  turned  as  a  whole. 
The  points  most  likely  to  suffer  from   pressure  are  those  at  the 


FRACTURE   OF   THE    HIP TREATMENT  273 

junction  of  the  thigh-band  and  stem,  the  lower  bend  of  the  stem, 
and  the  junction  of  the  stem  and  chest-band.  Points  pressed 
upon  should  be  lightly  dressed  with  flexible  collodion  and  pro- 
tected from  further  pressure  by  padding  above  and  below.  If 
the  pressure  of  the  whole  body  portion  of  the  stem  is  complained 
of,  a  small,  thin  mattress  of  hair  or  a  sheet  folded  to  several 
thicknesses  may  be  placed  between  the  splint  and  the  patient's 
back.  Threatened  hypostatic  congestion  is  obviated  by  raising 
the  head  of  the  bed  from  one  to  three  feet,  the  patient  meanwhile 
being  prevented  from  slipping  down  by  tying  the  splint  to  the 
head  of  the  bed.      In  all  cases  obviously  unimpacted  and  in  all 


Fig.  372. — Skiagram  tracing  of  patient  two  and  a  half  years  of  age,  after  the  accident, 
illustrating  the  deformity  of  the  neck  and  of  the  upper  extremity  of  the  shaft,  also  the  eleva- 
tion of  the  pelvis  on  the  affected  side  (after  Whitman). 


cases  when  the  shortening  is  more  than  three-fourths  of  an  inch, 
traction  should  be  applied. 

"  In  all  cases  the  splint  should  be  kept  on  for  from  six  to  eight 
weeks  after  all  pain  has  ceased  ;  then  the  patient  should  remain 
in  bed  four  weeks  longer  without  any  treatment  whatever,  unless 
there  is  some  positive  indication  to  the  contrary,  in  which  case 
the  splint  is  cut  off  at  the  knee  and  the  calf-band  riveted  at  this 
point  and  the  patient  permitted  to  go  about  with  crutches." 

In  addition  to  the  use  of  the  Thomas  splint,  it  may  be  wise  to 
make  lateral  pressure,  as  suggested  by  Senn,  over  the  trochanter 
of  the  broken  hip  with  the  expectation  of  more  firmly  fixing  the 
broken  bone.  Lateral  pressure  may  be  secured  by  a  surcingle 
or  by  a  bandage  applied  over  a  graduated  compress.      The  spot 


274 


FRACTURES    OF    THE    FEMUR 


to  which   pressure  is  applied  should  be   carefully  watched   and 
protected. 

The  Operative  Treatment. — Suturing  or  pegging  the  fragment 
is  very  properly  to  be  reserved  for  fractures  occurring  in  young 
adults  in  whom  the  absolute  fixation  by  the  Thomas  splint  for  a 
reasonable  period  has  not  affected  union. 


Fig.  373  —Tracing  of  photograph  of  patient  eight  years  old,  some  years  after  a  fra<  lure 
of  the  neck  of  the  right  femur,  showing  great  projection  and  elevation  of  the  trochanter, 
made  more  apparentby  flexing  the  thigh  and  leg  <  Whitman). 


Fracture  of  the  Neck  of  the  Femur  in  Childhood. — Whit- 
man has  called  especial  attention  to  this  fracture.  The  anatom- 
ical proof  of  the  existence  of  fracture  of  the  neck  of  the  femur  in 
childhood  has  been  furnished  by  the  specimens  of  Bolton,  Meyers, 
and  Starr.      The  fracture  occurs  after  traumatism  to  the  hip  prob- 


Head  of  femur. 


Marks  upper  limit  of  head  of  bone. 


Fig-  374- — Case  :     Girl  13  years  of  age.     Old  fracture  of  shaft  of  femur  with  vicious  union. 
Fresh  fracture  of  neck  of  femur. 


275 


276  FRACTURES    OF    THE    FEMUR 

ably  more  frequently  than  separation  of  the  upper  femoral  epiphy- 
sis. It  is  not  so  uncommon  an  accident  as  has  been  supposed. 
The  fracture  is  probably  impacted  or  green  stick.  The  clinical 
picture  of  fracture  of  the  neck  of  the  femur  in  childhood  differs 
greatly  from  that  furnished  by  a  similar  injury  in  old  age.  In 
the  first  instance  a  healthy  child  falls  from  a  height,  and  presents 
a  shortening  of  the  thigh  of  from  y',  to  34  of  an  inch.  There 
are  slight  outward  rotation  of  the  leg  and  limitation  of  motion  and 
slight  discomfort  in  the  hip.  The  child  may  walk  about  after 
a  few  days  with  but  a  little  lameness  to  suggest  that  any  injury 
has  been  received.  The  child  recovers  with  a  limp.  Months 
or  years  later  signs  of  coxa  vara  appear.  In  childhood  a  rather 
severe  injury  is  followed  by  immediate  symptoms,  and  later 
by  great  disability.  On  the  other  hand,  in  old  age  a  trivial 
injury  is  followed  by  immediate  and  complete  disability.  It  is 
often  overlooked  in  the  child  and  is  treated  for  a  contusion  or 
sprain  of  the  hip.  The  immediate  result,  however,  is  extremely 
good  even  without  more  than  bed  treatment,  but  the  ultimate 
result  after  several  months  or  years  may  be  disastrous  because 
of  the  disability  due  to  a  gradually  increasing  bending  of  the 
femoral  neck.  The  late  result  of  fracture  of  the  femoral  neck  in 
childhood  resembles  hip-disease  in  the  limp,  slight  pain,  short- 
ening, deformity,  and  limitation  of  motion  present.  Care  must 
be  taken  not  to  confound  the  two  conditions.  These  later  stages 
of  fracture  are  to  be  treated  by  rest  to  the  joint.  All  body- 
weight  and  the  jar  of  walking  are  to  be  removed  by  a  properly 
fitting  hip-splint  with  traction.  Refracture  and  operative  meas- 
ures are  to  be  seriously  entertained,  as  in  other  forms  of  coxa 
vara,  particularly  if  the  disability  is  great  or  is  increasing  (see 
Figs.  373— 37<S  inclusive). 

The  treatment  of  a  fresh  greenstick  or  impacted  fracture  of 
the  hip  in  children  should  be  by  rest  on  the  back  in  bed 
and  moderate  traction  and  immobilization  of  the  hip  and 
thigh  and  body.  After  a  month  the  child  may  be  allowed  up, 
wearing  a  traction  hip-splint  for  several  months  until  union  is  so 
firm  that  the  danger  from  coxa  vara  is  practically  eliminated.  A 
light  plaster-of- Paris  spica  bandage  from  calf  to  axilla  will  main- 
tain immobility  after  the  splint  is  omitted. 


277 


278 


FRACTURES    OF    THE    FEMUR 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR 
Fracture  of  the  shaft  of  the  femur  is  usually  oblique.  It  is 
situated  either  just  below  the  lesser  trochanter  (subtrochanteric 
fracture),  at  the  center  of  the  shaft,  or  above  the  condyles 
(supracondyloid  fracture).  Even  in  closed  fractures  there  is 
sometimes  great  damage  to  the  soft  parts  :  the  vessels  of  the 
thigh  are  at  times  injured. 

Symptoms. — There  is  often  great  swelling  at  the  seat  of 
fracture.  The  limb  lies  helpless.  Pain,  abnormal  mobility, 
deformity,  marked  lateral  rolling  of  the  leg  below  the  seat  of  the 


Fig.  379. — Fracture  of  the  thigh  at  the  middle.     Characteristic  deformity. 


fracture,  and  crepitus,    one  or  all,   may   be    evident  (see    Figs. 
379,  380).      The  limb  is  shortened. 

Measurement  (see  Figs.  383-386  inclusive)  to  determine  the 
amount  of  the  shortening  is  to  be  made  from  the  anterior  superior 
spinous  process  of  the  ilium  to  the  internal  malleolus  of  the  same 
side.  Great  care  must  be  exercised  in  taking  this  measurement 
so  that  the  patient  lies  flat  upon  the  back  upon  a  hard  and  even 
surface,  with  the  arms  at  the  sides  of  the  body  and  with  no  pillow 
under  the  head  or  shoulders.  The  long  axis  of  the  body  should 
be  in  the  same  line  with  the  long  axis  between  the  legs  as  they 
lie  with  the  malleoli  approximated — i.  e.,  the  chin,  episternal 
notch,  umbilicus,  the  symphysis  pubis,  the  midpoint  between  the 
knees,  and  the  midpoint  between  the  internal  malleoli  should  all 


THE  SHAFT  OF  THE  FEMUR 


2/9 


be  in  one  straight  line  (sec  Fig.  386).  The  line  joining  the  ante- 
rior superior  spinous  processes  of  the  ilia  should  be  at  right  angles 
to  this  long  axis  of  the  body  and  thighs.  Any  variations  from 
this  normal  position  arc  attended  by  errors  in  measurement, 
which  are  important.  If  for  any  reason  the  injured  thigh  can  not 
be  brought  easily  alongside  its  fellow,  the  two  limbs  should  be 
placed  as  nearly  symmetrical  with  reference  to  the  median  line 
as  possible. 

The  method  of  measuring  the  lengths  of  the  lower  extremities 
used  by  Dr.  Keen  differs  from  the  above  in  that  he  uses  the 
malleolus  as  the  fixed  point,  and  measures  to  a  line  drawn  at  the 


Fig.  380. — Fracture   of  the  right  femur  at  the  middle.     Characteristic  deformity.     Inward 
rotation  of  leg  below  fracture. 


anterior  superior  spinous  process  of  the  ilium.  The  finger  and 
tape  are  not  allowed  to  touch  the  skin-mark,  and  so  do  not  dis- 
place it. 

Treatment  of  Fracture  of  the  Shaft  of  the  Femur. — The 
Transportation  of  a  Patient  :  The  emergency  method  of  put- 
ting up  a  fracture  of  the  thigh  or  hip  is  of  very  great  practical 
importance  (see  Fig.  387).  Limbs  are  fractured  frequently  some 
distance  from  the  proper  place  for  the  application  of  the  perma- 
nent dressing.  It  is  necessary  to  transport  such  cases  with  the 
greatest  degree  of  safety  and  comfort.  In  order  to  accomplish 
this  the  knee-  and  hip-joints  should  be  extended,  the  leg  being 


Ill  9 


Fig.  381.— Fracture  of  the  upper  third  of  the  shaft  of  the  right  femur  (X-ray  tracing). 


Fig.  382. — Long  oblique  fracture  "i  theshafl  .>i  the  femur  (Massachusetts  General  Hospital, 

1250.     X-ray  tracing). 

280 


THE  SHAFT  OF  THE  FEMUR 


28l 


held  straightened  in  the  long  axis  of  the  body.  The  limb 
should  be  placed  upon  a  heavily  padded  board,  the  width  of 
the  thigh,  extending  from  the  middle  of  the  calf  to  above 
the  sacrum.  The  side  splints  of  wood  should  be  used — one 
on  the  outer  side  extending  from  the  side  of  the  foot  to  the 
axilla,  the   other   upon   the  inner  side   extending  from  the   side 


Fig.  383 — Fracture  of  the  thigh.     Correct  method  of  measurement  from  the  anterior  superior 
spinous  process  of  the  ilium.     Position  of  thumb  and  finger  holding  tape. 


Fig.  384. — Measurement  of  lower  extremity.     Position  of  thumbs  shown.     Note  position  of 

limb. 


of  the  foot  to  a  few  inches  below  the  perineum.  Upon  the 
front  of  the  thigh  is  placed  a  coaptation  splint  extending 
from  the  groin  to  the  patella.  All  of  these  splints  are  care- 
fully padded,  preferably  with  folded  sheets  or  pillow-cases  or 
towels  ;  of  course,  in  emergency  work  small  pillows  or  coats  or 
shawls   may  be   utilized.      It  is  important  that  the  padding  be 


282 


FRACTURES    OF    THE    FEMUR 


evenly  and  intelligently  arranged.  It  will  be  necessary  to  place 
a  wide  pad  between  the  upper  end  of  the  long  outside  splint,  to 
prevent  it  from  pressing  upon  the  ribs  and  side  of  the  chest  and 
causing  great  discomfort.  These  splints  are  held  in  position 
about  the  leg,  while  gentle  traction  is  being  made  upon  the 
limb  by  straps  or  pieces  of  bandage  placed  above  the  ankle, 
below  the  knee,  above  the  knee,  at  the  middle  of  the  thigh, 
and  at   the   level    of   the    perineum.     The    upper    end    of   the 


Fig.  385. — Measurement  of  lower  extremity.     Patient  lying  on  the  back  looked  at  from  above. 
Positions  of  tape,  hands,  and   limb  to  be  noted. 


long  outside  splint  is  held  to  the  side  by  a  swathe  about 
the  body  and  splint.  The  patient  should  then  be  careful ly 
placed  upon  a  stretcher  (a  Bradford  frame  is  an  ideal  form  of 
stretcher)  improvised  for  the  occasion.  With  this  apparatus 
snugly  applied,  the  patient  may  be  securely  and  comfortably 
transported. 

The    objects  of  treatment  are  to  reduce  the  fracture,  to  main- 
tain the  reduction  immobilized  until  union  is  firm,  and  to  restore 


THE    SHAFT    <)!•'    THE    FEMUR 


283 


the  leg  to  its  normal  usefulness.  In  the  treatment  of  two  of  the 
three  varieties  of  fracture  of  the  femur  permanent  traction  upon 
the  lower  fragment  and  permanent  countertraction  upon  the 
upper  fragment  are  necessary. 


Fig.  386. — Measurement  of  the  length  of  the  lower  extremity.  Patient  represented  lying 
on  back,  looked  at  from  above.  The  line  joining  the  anterior  superior  spinous  processes  of 
ilia  (C,  If))  should  be  at  right  angles  to  the  long  axis  of  the  body  (A,  B).  In  this  position  only 
can  comparable  measurements  be  made.     (Drawn  by  C.  Rimmer.) 


The  patient  with  a  fractured  thigh  should  always  be  anesthe- 
tized before  putting  the  thigh  up  permanently.  Never  anesthetize 
the  patient  until  all  the  different  parts  of  the  apparatus  are  ready 
and  on  a  table  near  the  bed  of  the  patient.  Always  put  the 
thigh  up  in  temporary  dressings  until  all  is  prepared  for  the  per- 


284 


FRACTURES    OF    THE    FEMUR 


manent  splints.  About  one  hour  will  be  consumed  in  applying  the 
extension  apparatus  after  the  patient  is  anesthetized.  There  will 
be  no  harm  in  letting  the  patient  rest  comfortably  in  the  tempo- 
rary splints  over  one  night  until  all  necessary  arrangements  have 
been  made  for  the  permanent  dressing. 

Method  of  Examination  :  The  patient  is  completely  anesthe- 
tized in  order  to  secure  muscular  relaxation.  Accurate  examina- 
tion is  now  made  of  the  fracture.  If  the  ends  of  the  fragments  lie 
close  to  the  skin,  great  care  must  be  exercised,  by  steadying  the 


Fig.  387. — Fracture  of  hip  or  thigh.     Emergency  apparatus. 


Fracture  of  the  thigh.     Method  of  holding  leg  in  order  to  detect  fracture  of  the 
thigh.     Pelvis  is  steadied  by  an  assistant. 


thigh,  to  prevent  them  being  pushed  through  the  skin  and  thus 
rendering  the  fracture  an  open  one.  An  assistant  should  steady 
the  pelvis  and  upper  thigh  (see  Fig.  388).  The  surgeon  should 
grasp  the  thigh  above  the  condyles  with  both  hands,  and  should 
make  traction  in  the  axis  of  the  limb.  lie  then  determines  the 
pull  necessary  to  be  exerted  to  hold  the  fragments  reduced. 
While  this  pull  is  maintained  by  an  assistant,  the  surgeon  manip- 
ulates the  thigh  in  order  to  learn  with  what  ease  or  difficulty  the 
fragments  may  be  held  in  position. 


THE   SHAFT    OF    THE    FEMUR 


:85 


In  adults  in  fracture  of  the  middle  of  the  shaft  of  the  femur 
traction  and  immobilization  are  best  maintained  by  a  modified 
Buck's  extension  apparatus.  Materials  needed  for  a  modified 
Buck's  extension  :  Two  strips  of  adhesive  plaster,  each  two 
inches  wide  and  long  enough  to  extend  from  the  seat  of  fracture 
to  the  internal  malleolus.  Surgeon's  adhesive  plaster  is  nonirri- 
tating  to  the  skin,  and  is  prepared  in  rolls  of  convenient  width. 
To  each  strip  of  plaster  at  the  ankle  end  should  be  stitched  a 
piece  of  webbing  the  width   of  the  plaster  and  about  six  inches 


-Pulley  arranged  on  broom-handle  to  be  fastened  at  foot  of  bed  for  carrying  exten- 
sion cord. 


long.  Prepare  five  other  strips  of  adhesive  plaster,  all  of  which 
should  be  one  and  a  half  inches  wide.  Three  of  these  strips 
should  be  long  enough  to  encircle  respectively  the  leg  above  the 
malleoli,  the  knee  above  the  condyles,  and  the  thigh  an  inch 
below  the  seat  of  the  fracture.  The  remaining  two  strips  of 
plaster  should  be  long  enough  to  extend  spirally  from  the  mal- 
leoli around  the  leg  and  thigh  to  the  seat  of  fracture.  Prepare 
also  a  roller  bandage  of  gauze  or  cotton  cloth,  a  curved  or  straight 
ham-splint  properly  padded,  and  three  adhesive  straps  for  hold- 
ing the  ham-splint. 


286 


THE  SHAFT  OF  THE  FEMUR  287 

In  addition,  three  coaptation  splints  for  surrounding  the  thigh 
are  required,  also  six  webbing  straps  with  buckles  or  strips  of 
bandage  to  be  used  as  straps  ;  fresh  sheets  or  pillow-cases  or 
towels  for  padding  ;  a  swathe,  to  encircle  the  pelvis,  made  of 
unbleached  cotton  cloth  or  medium  weight  Shaker  flannel  ;  and 
a  long  outside  splint  of  wood,  four  inches  wide,  to  extend  from 
the  axilla  to  six  inches  below  the  sole  of  the  foot.  To  this  last 
a  cross-piece,  eighteen  inches  long,  should  be  fastened,  making 
thus  a  long  T-splint.  The  list  is  completed  by  two  towels  for 
perineal  straps,  safety-pins,  a  pulley,  which  can  be  bought  at  little- 
cost  at  any  hardware  store  (see  Fig.  389).  This  pulley  should 
be  screwed  into  a  broom-handle  cut  to  the  right  height.     A  block 


Fig.  391. — Pulley  arranged  for  bed. 

with  hooks  above  and  a  pulley  below  will  sometimes  be  found  to 
be  more  convenient  than  the  broom-handle  arrangement  (see 
Fig-  390-  A  spreader  (see  Fig.  392),  which  is  a  piece  of  wood 
two  inches  wide  and  a  little  longer  than  the  width  of  the  foot, 
perforated  at  its  center  for  the  extension  weight  cord.  There 
should  be  provided  a  cord,  three  feet  long,  size  of  a  clothes-line  ; 
ttvo  bricks  or  wooden  blocks  for  elevating  the  foot  of  the  bed  ; 
four  sand-bags,  twenty  inches  long  and  six  inches  wide  ;  a  cradle 
(see  Figs.  393,  394)  to  keep  the  weight  of  the  clothes  from  the 
thigh — the  cradle  may  be  a  chair  tipped  up,  or  barrel-hoops 
nailed  together. 

Application    of    the    Modified    Buck's    Extension. — All    the 
materials  being  in  readiness  and  at  hand,  the  patient  having  been 


288 


FRACTURES    OF    THE    FEMUR 


etherized  and  the  fracture  examined,  the  thigh  and  leg  and  foot 
are  first  washed  with  warm  water  and  Castile  soap  and  thor- 
oughly dried.  The  long  straight  strips  of  adhesive  plaster  with 
the  webbing  attached  are  applied  to  the  middle  of  the  two  sides 
of  the  leg  and  thigh  up  to  the  seat  of  fracture.  The  junction  of 
the  adhesive  plaster  and  webbing  should  be  brought  to  just 
above  the  malleoli.  The  two  spiral  and  then  the  three  circular 
strips  should  next  be  applied  as  indicated  (see  Fig.  395).  Over 
the    extension   is  placed  a   roller  bandage,   snugly   and    evenly 


Fig.  392.— Spreader  of  wood  for  preventing;  extension  straps  from  chafing  ankle  and  foot. 
Cord  for  attaching  weight. 


inclosing  the  foot.  The  bandage  steadies  the  adhesive  plaster, 
prevents  swelling  of  the  foot,  and  affords  comfort.  Then  the 
padded  posterior  coaptation  or  ham-splint  is  applied  and  held  by 
three  straps  of  adhesive  plaster,  one  at  each  end  of  the  splint 
and  one  below  the  knee  (see  Fig.  396).  If  the  curved  ham-splint 
is  used,  the  padding  (one  sheet  of  sheet  wadding)  should  be  laid 
upon  the  splint  evenly  throughout.  If  a  straight  ham-splint  is 
used,  the  padding  should  be  applied  evenly,  and  at  the  middle  of 
the  ham,  behind  the  knee,  should  be  placed  an  additional  pad  (see 
Fig.  397)  in  order  to  support  the  knee  in   its  natural  position. 


THE  SHAFT  OK  THE  FEMUR 


289 


This  additional  pad  should  be  placed  between  the  splint  and  the 
layer  of  sheet  wadding.  The  tendency  of  the  padding  of  the 
ham-splint  is  to  slip  away  from  each  end  of  the  splint  and  thus 
leave  it  unduly  pressing  into  the  thigh  and  calf.  It  is  wise  to 
hold  this  padding  in  place  by  strips  of  adhesive  plaster  at  each 
end  of  the  splint.  The  three  thigh  coaptation  splints  should  be 
next  put  in  position — one  anteriorly,  extending  the  whole  length 


Fig.  393. — Cradle  lo  keep  clothes  from  leg.     Made  from  two  barrel-hoops. 


Fig.  394. — Cradle  to  keep  clothes  from  leg.     Made  from  two  barrel-hoops. 


of  the  thigh  from  groin  to  patella  ;  one  externally,  extending 
from  trochanter  to  external  condyle  ;  and  one  internally,  extend- 
ing from  just  below  the  perineum  to  just  above  the  adductor 
tubercle  (see  Fig.  397).  The  best  padding  for  these  splints  is 
a  towel  folded  the  length  of  the  splints  and  placed  evenly  about 
the  thigh.  These  splints  are  held  by  an  assistant  while  three  or 
four  straps  are  tightened  sufficiently  to  hold  them  firmly  in  place. 
While  these  coaptation  splints  are  being  applied  it  is  very  impor- 
19 


Fig.  395.  —  Fracture  of  the  thigh.     Adhesive-plaster  extension  strips;  long  upright,  circular, 
and  obliquely  applied  stiips. 


Fig.  396. — Fracture  of  the  thigh.     Extension  strips  applied,  covered  by  bandage.     Hani-splint 
applied  ;   two  straps  and  pad  in  ham. 


Fig.  397. — Fracture  of  the  thigh.     Extension  strips  applied.    Cotton  bandage.     Ham-splint, 
straps,  pad,  and  coaptation  splints  about  the  seat  <>i  Fracture.    Straps  and  buckles. 

290 


THE  SHAFT  OF  THE  FEMUR 


291 


tant  that  stead}-  traction  be  made  upon  the  lower  fragment  in 
order  to  maintain  its  reduction.  The  straps  of  the  coaptation 
splints  are  then  finally  tightened.  The  long  outside  splint  with 
the  T  cross-piece  is  then  padded  with  sheets  and  applied  to  the 
side  of  the  limb  and  the  body  (see  Fig.  398).  The  upper  end  of 
the  splint  is  inclosed  in  a  swathe,  which  passes  around  the  body 
and   is  fastened  with   safety-pins.     The  thigh  and   leg  are   held 


-Fracture  of  the  thigh.  Completed  apparatus  as  in  figure  397,  and  in  addition  a  lonj 
outside  T-spliut,  straps,  and  swathe.     Weights  applied. 


Fig.  399. — Fracture   of  the  thigh.     Completed  apparatus  with  hed  elevated.     The  outside 
splint  is  broad  and  without  the  T  foot-piece.     The  swathe  is  very  snugly  applied. 


steadily  to  the  outside  splint  by  two  or  three  straps  (see  Fig. 
399).  The  assistant,  making  extension,  exchanges  his  traction 
for  that  of  the  weight  and  pulley.  The  foot  of  the  bed  is  raised 
upon  blocks  or  bricks,  in  order  to  provide  the  counterextension 
by  means  of  the  weight  of  the  body.  The  heel  is  protected  from 
undue  pressure  by  a  ring.  The  foot  is  kept  at  a  right  angle  with 
the  leg  (see  Figs.  400,  401).      The  sand-bags  are  laid  along  the 


292 


FRACTURES    OF    THE    FEMUR 


inner  and  outer  sides  of  the  limb  to  add  greater  steadiness  to  the 
apparatus.      The  cradle  is  placed  over  the  foot  and  leg. 

Throughout  the  course  of  the  treatment  of  a  fracture  of  the 


Fig.  400.  Fig.  401. 

Figs.  400,  401. —  Forms  of  stirrup  to  prevent  the  foot  assuming  an  equimis  position. 


Fig.  402. — Diagram  of  section  of  leg  and  splint  to  show  how  a  strap  carried  from  the  back 
of  the  leg  over  the  long  side-splint  can  prevent  eversion  of  the  foot  and  leg. 


-The  more  usual  deformities  in  fracture  of  the  shaft  of  the  femur.    Outward  and 
posterior  bowing. 


i  in.  si i  \i  i    of   tiif:   FEMI  l: 


293 


thigh  it  is  necessary  to  be  positive  of  four  things  :  (a)  The 
absence  of  shortening  in  the  injured  thigh  ;  (p)  the  prevention  of 
outward  bowing  of  the  thigh  ;  (c)  the  prevention  of  permanent 
rotation  of  the  leg  and  lower  thigh  outward  below  the  seat  of 
fracture  ;  and  finally  (d),  the 
prevention  of  a  sagging  back- 
ward of  the  thigh  at  the  seat 
of  fracture,  causing  what  ap- 
pears on  standing  as  a  false 
genu  recurvatum. 

{ci)  The  shortening  of  the 
injured  leg  is  prevented  by  a 
sufficiently  heavy  weight  for 
extension.  This  weight  can 
be  approximately  but  not  ac- 
curately determined.  Ordin- 
arily, in  an  adult  fifteen  or 
twenty  pounds  are  needed  to 
hold  the  fragments  in  proper 
position.  Comparative  meas- 
urement of  the  legs  from  an- 
terior superior  spinous  pro- 
cess to  the  malleolus  should 
be  made  regularly  every  other 
day,  and  the  measurements 
recorded  during  the  first  two 
weeks  of  immobilization  and 
the  extension  weight  corre7 
spondingly  adjusted. 

(/;)  In  order  to  prevent  any 
outward  bowing  of  the  thigh, 
the  thigh  and  leg  should  be 
slightly    abducted    after    the 

apparatus  is  applied,  so  that  the  extension  is  made  with  the  limb 
in  this  abducted  position  (see  Fig.  404). 

(c)  In  order  to  prevent  the  thigh  from  rotating  outward  below 
the  fracture  and  thus  carrying  the  leg  and  foot  with  it, — to  pre- 
vent, in  other  words,  eversion  of  the  foot, — a  bandage  six  inches 


V.;: 


Fig.  404. —  Showing;  the  necessity  of  ab- 
ducting the  injured  leg:  in  thigh  fracture.  In 
dotted  line  is  shown  the  position  likely  to  re- 
sult from  neglect  of  this  abduction. 


294 


FRACTURES    OF    THE    FEMUR 


wide  should  be  fastened  by  pins  below  the  calf  of  the  leg  to  the 
posterior  part  of  the  bandage  or  ham-splint,  and  brought  up  on 
the  outer  side  of  the  leg  and  fastened  to  the  long  outside  splint 
or  to  the  cradle  above.     The  leg  meanwhile  is  held  in  the  cor- 


Fig.  406.—  Case  :  Oblique  subtrochanteric  fracture 
of  shaft  of  femur  (X-ray  tracing). 


Fig.  40=;. — Action  of  the  muscular 
pull  of  the  iliopsoas  and  of  the  external 
rotators  in  producing  deformity  in  frac- 
ture ol  tin--  femur  hi^li  up.  Upper  frag- 
ment is  flexed  and  abducted  upon  the 
trunk. 


rected  position.      If  this   bandage  is  fastened  to  the  cradle,  the 
latter  should  be  fastened  firmly  to  the  bed. 

(rt?)  .The  sagging  backward  of  the  thigh  (set:  Fig.  403)  is 
prevented  by  the  posterior  coaptation  splint  and  its  proper  pad- 
ding.    (See  Supracondyloid  Fracture  of  the  Femur.) 


SUUTKOCHANTKKIC     FRACTURE 


295 


Subtrochanteric  Fracture  of  the  Shaft  of  the  Femur. — 
Fractures  of  the  upper  third  of  the  shaft  are  comparatively 
rare.  The  diagnosis  of  this  fracture  is  not  ordinarily  difficult. 
The  displacement  is  characteristic  :  The  upper  fragment  is  flexed 
and  abducted,  and  the  lower  fragment  overrides  the  upper  one 
and  is  slightly  adducted.  The  treatment  should  restore  the  line 
of  the  thigh.  At  times  the  ordinary  extension  and  counterex- 
tension,  as  for  a  fracture  of  the  middle  of  the  femur,  may  prove 


Fig.  407. — Spiral  fracture  of  the  shaft  of  the 
femur  high  up  (X-ray  tracing). 


Fig.  408. — Spiral  fracture  of  the  upper 
half  of  the  femur.  View  from  in  front  and 
externally    (Warren     Museum,    specimen 

in- 


effective. If  it  is  not  effective, — and  it  usually  is  not, — the  leg 
and  lower  fragment  should  be  elevated  upon  an  inclined  plane 
(see  Fig.  422),  so  as  to  bring  the  lower  fragment  up  to  the  upper 
one,  for  it  will  be  found  impossible  to  lower  the  upper  fragment. 
Traction  should  then  be  made  in  the  line  of  the  elevated  thigh 
from  above  the  condyles  of  the  femur.  If  position  and  traction 
are  inefficient, — and  they  usually  are, — then  suturing  of  the 
fragments  should  be  contemplated. 

It  will  be  found  impossible  to  correct  completely  the  ordinal}- 


296 


FRACTURES    OF    THE    FEMUR 


deformity  of  abduction  and  flexion  of  the  upper  fragment  and 
adduction  and  riding  up  of  the  lower  fragment  by  traction  upon 
the  lower  fragment,  no  matter  in  what  position  the  lower  frag- 
ment may  be  placed  for  traction.  Rendering  the  closed  fracture 
open  by  incision  and  suturing  the  bones  in  position  is  the  only 
possible  way  of  securing  a  perfect  result  either  anatomically  or 
functionally.  The  surgeon  must  be  judicious  in  the  selection  of 
the  patients  upon  whom  he  operates.      Even  though  old,  if  the 


Fig.  409. — Same  speci- 
men as  figure  408,  from  be- 
laud. 


Fig.  410.  —  Fractured 
femur,  base  of  neck  driven 
into  the  shaft.  Spiral  frac- 
ture of  shaft  just  below  this 
(Warren  Museum,  6529). 


Fig.  411.  —  Fracture  of 
shaft  of  femur  high  up  ; 
union  with  much  displace- 
ment (Warren  Museum, 
specimen  5993). 


patient  is  in  excellent  general  health,  the  operation  may  be  done 
with  every  prospect  of  success. 

Supracondyloid  Fracture  of  the  Femur. — The  deformity  is 
characteristic  and  fairly  typical  (see  Figs.  414,  41  5) ;  displacement 
of  both  fragments  backward  is  sometimes  seen  (see  Fig.  420). 
The  upper  end  of  the  lower  fragment  is  displaced  backward, 
chiefly  through  the  pull  upon  it  by  the  gastrocnemius  muscle. 

I  reatment  of  this  fracture  in  the  straight  and  extended  posi- 
tion is  usually  unsatisfactory.  It  is  necessary  either  to  flex  the 
leg  in  order  to  relax  the  gastrocnemius   muscle  or  to  do  a  ten- 


SUI'KACONDYLOID    FRACTURE 


297 


otomy  upon  the  tendo  Achillis.  One  of  these  procedures  having 
been  carried  out,  the  thigh  and  leg  should  then  be  placed  upon 
a  double  inclined  plane  (see  Fig.  422).  Pressure  by  pads  may 
be  exerted  upon  the  upper  end  of  the  lower  fragment  in  order  to 
lift  it  forward  into  apposition  with  the  upper  fragment.  Slight 
traction,  if  possible,  should  be  maintained  upon  the  lower  frag- 
ment. Repeated  examinations  with  the  fluoroscope  will  indicate 
when  reduction  is  completed. 

The   After-treatment   and  Progress    of   Fracture   of  the 
Thigh. — Inspection    of  the   fractured  limb   should   be   made   at 


Fig.  412. — Fractures  of  base  of  neck  and 
trochanters  of  femur.  View  from  behind 
and  inner  side  (Warren  Museum). 


Fig.  413. — Fracture  well  below  trochan- 
ters, with  a  split  running  upward  through 
great  trochanter.  Also  fracture  of  neck  of 
bone  with  displacement  of  head  up  and 
out.  Recent  case  (Warren  Museum,  speci- 
men 1074). 


least  daily.  Measurement  should  be  made  twice  a  week  during 
the  first  few  weeks,  the  internal  malleolus  being-  reached  through 
the  bandage.  Parts  of  the  apparatus  may  need  changing,  and 
straps  may  require  tightening  or  loosening.  The  heel  and  sacrum 
will  require  attention  because  of  the  constant  pressure  from  lying 
in  one  position. 

Ordinarily,  there  will  be  little  or  no  pain  associated  with  the 
repair  of  the  fracture.  After  about  four  weeks  all  apparatus 
should  be  removed  and  the  limb  thoroughly  inspected,  to  detect, 
if  possible,  any  uncorrected  deformity,  and  to  determine  whether 
union  is    yet  firm.       In  from  four    to    six  weeks    repair    in    a 


298 


FRACTURES    OF  .THE    FEMUR 


healthy  child  or  young  adult  should  have  advanced  to  the  stage 
of  firm  union.  The  apparatus  should  then  be  reapplied.  At 
the  end  of  the  eighth  week  all  apparatus  should  be  finally 
removed.  The  thigh  should  be  washed  and  thoroughly  oiled. 
The  patient  should  be  permitted  to  lie  in  any  position  in  bed 
without  retentive  apparatus  for  one  week.  After  the  splints  are 
first  left  off  and  while  the  patient  is  still  in  bed  daily  systematic 
massage  to  the  whole  limb  should  be  practised,  together  with 
slight  passive  and  active  motion  at  the  knee-joint.  The  patient 
should  not  be  allowed  to  bear  weight  upon  the  unprotected  thigh 
until   after   the   ninth  week.      At   the  ninth  week  he  should  be 


Lower  fragment  of  femur 


Gastrocnemius  muscle 


Upper  fragment  of  femur. 


Patella. 


Fig.  414.— Action  of  gastrocnemius  muscle  pulling  distal  fragment  backward  and  downward. 

allowed  up  and  about  with  crutches,  and  a  moderately  high-soled 
shoe  (two  inches)  should  be  worn  upon  the  foot  of  the  uninjured 
thigh.  He  should  bear  no  weight  upon  the  injured  leg.  The 
seat  of  the  fracture  should  be  protected  by  coaptation  splints  and 
straps  and  a  light  spica  plaster-of- Paris  bandage  from  the  toes 
to  above  the  waist.  At  the  end  of  twelve  weeks  all  support  may 
be  discarded.  ( )f  course,  fractures  of  the  femur  vary  considerably 
in  the  time  the  patient  is  able  to  get  about,  but  the  foregoing 
routine  is  that  of  average  uncomplicated  cases. 

It  is  very  probable  that  massage  without  any  passive  motion, 
as  early  as  the  second  week,  to  the  region  of  the  knee  and  thigh, 
will  prevent  much  of  the  knee-joint  disability  and  muscular 
atrophy  that  SO  often  hinder  convalescence  in  these  cases.      It  is 


THE    AMBULATORV    TREATMENT 


299 


very  important  also,  in  order  to  gain  this  end,  to  see  that  the  ex- 
tension is  made  from  around  and  above  the  condyles  of  the  femur 
and  not,  as  so  often  happens,  from  the  knee-joint  itself.  It  ought 
to  be  possible  to  avoid  all  knee-joint  stiffness  by  the  judicious 
use  of  massage  to  the  whole  limb  and  passive  motion  to  the 
knee-joint.  These  measures  in  many  cases  should  be  instituted 
and  practised  regularly  and  persistently  and  always  cautiously 
from  the  second  week  after  the  injury. 

The  ambulatory  treatment  of  fracture  of  the  thigh  by  means 
of  the  long  Taylor  hip  traction  splint,  a  high  sole  upon  the 
shoe  worn  on  the  well  foot,  and  crutches,  is  of  very  great  value, 
especially  in   children  and  young  adults.     The  hip-splint,  con- 


Shaft  of  femur. 


Condyles  and  lower  fra.F-  - 
ment  of  femur. 


Patella. 


I Tibi 


Fig.  415. — Low  fracture  of  the  shaft  of  the  femur.  Displacement  of  the  lower  fragment 
backward  by  the  gastrocnemius  muscle,  and  of  the  upper  fragment  forward.  Overlapping 
of  fragments. 


sisting  of  a  long  outside  upright,  pelvic,  thigh,  and  calf  bands,  is 
applied  with  two  perineal  straps  (see  Figs  423,  424).  The  trac- 
tion is  made  through  the  windlass  at  the  foot-piece  after  fastening 
the  extension  strips  to  it.  The  countertraction  is  made  by  the  two 
perineal  straps.  The  thigh  is  securely  held  by  coaptation  splints 
and  a  bandage  about  the  thigh  and  splint.  The  patient  goes 
about  with  crutches  and  a  high  sole  of  two  inches  upon  the  shoe 
worn  on  the  well  foot,  bearing  a  little  weight  upon  the  foot  of  the 
splint.  As  a  matter  of  fact,  the  real  value  of  this  method  in 
fracture  of  the  thigh  lies  in  the  improvement  to  the  general  health 
by  the  early  getting  into  the  upright  position  and  out  of  bed. 
This  application  of  the  ambulatory  method  certainly  is  of  great 
comfort  to  the  patient.      That  it  hastens  the  reparative  process  is 


300 


FRACTURES    OF    THE    FEMUR 


yet  to  be  fully  demonstrated.  If  the  Taylor  hip-splint  is  used,  it 
should  be  applied  when  union  is  found  to  be  firm.  After  wear- 
ing the  splint  in  bed  for  a  few  days  the  patient  may  get  up  and 
be  about. 

The  Prognosis. — What  shall  be  considered  a  satisfactory  re- 
sult in  the  treatment  of  a  closed  fracture  of  the  shaft  of  the  femur  ? 
The  degree  of  restoration  of  function  can  not  be  determined  with 
accuracy  until  about  one  year  has  elapsed  after  treatment  is  sus- 
pended.    The  following  six  requisites  for  a  satisfactory  result  fol- 


Fig.  416. — Lateral  view.  Oblique  fracture  of  the  shaft  of  the  femur  low  down.  Little 
backward  displacement  of  lower  fragment.  Considerable  shortening  of  thigh  from  forward 
displacement  of  upper  fragment.     Man  aged  forty.     Recovery. 

lowing  fracture  of  the  femur  are  those  reported  by  a  committee 
from  the  American  Surgical  Association,  and  generally  accepted 
as  forming  a  good  working  basis. 

For  a  result  to  rank  as  a  good  one,  it  must  be  established 
that  firm  bony  union  exists  ;  that  the  long  axis  of  the  lower 
fragment  is  either  directly  continuous  with  that  of  the  upper 
fragment  or  is  on  nearly  parallel  lines,  thus  preventing  angular 
deformity  ;  that  the  anterior  surface  of  the  lower  fragment  main- 
tains nearly  its  normal  relation  to  the  plane  of  the  upper  frag- 
ment,  thus   preventing   undue    deviation    of   the    foot    from    its 


PROGNOSIS 


30I 


normal  position  ;  that  the  length  of  the  limb  is  exactly  equal  to 
its  fellow  or  that  the  amount  of  shortening  falls  within  the  limits 
found  to  exist  in  ninety  per  cent,  of  healthy  limbs — namely,  from 
one-eighth  to  one  inch  ;  that  lameness,  if  present,  is  not  due  to 
more  than  one  inch  of  shortening  ;  that  the  conditions  attending 
the  treatment  prevent  other  results  than  those  obtained. 

Results  After  Fracture  of  the  Thigh. — The  prognosis  as 
to  the  usefulness  of  the  thigh  after  fracture  deduced  from  the 
statistics  available  is  of  little  value,   because  the  details  of  the 


Fig.  417. — Same  as  figure  416.     Anteroposterior  view. 


cases  are  not  presented  nor  is  any  discrimination  made  between 
the  seats  of  fracture  and  the  ages  of  the  patients.  Realizing 
these  facts,  I  have  very  carefully  examined  and  classified  the 
final  results  several  years  after  treatment  had  ceased  in  thirty- 
five  cases  of  uncomplicated  fracture  of  the  shaft  of  the  femur 
treated  at  the  Massachusetts  General  Hospital.  The  treatment 
in  all  cases  was  practically  the  same  :  a  Buck's  extension  with 
outside  T-splint,  or  a  long  Desault  apparatus,  and,  toward 
the  end  of  treatment,  a  plaster  spica  of  the  thigh,  groin,  and 
trunk,  with  crutches.      Even   though    this    number   of   cases   is 


;o2 


FRACTURKS    OF    THE    FEMUR 


relatively  small,  yet,  after  having  most  carefully  analyzed  them, 
it  seems  highly  probable  that  even  if  this  number  should  be 
increased,  the  ultimate  results  would  not  materially  differ.  These 
thirty-five  cases  having  been  arranged  in  three  groups,  according 
to  age  :  (a)  Those  of  childhood  ;  (b)  those  of  adult  life  ;   and  (c) 


Sequestrum. 


Fig.  418. — Oblique  fracture  of  the  shaft 
just  above  the  knee,  with  splitting  apart  of 
the  two  condyles.  Extreme  displacement ; 
necrosis  of  tip  of  upper  fragment.  Patient 
a  man  of  thirty-seven  years,  lived  for  five 
months  (Warren  Museum,  specimen  1118). 


Fig.  419.— Same  as  figure  418,  view  from 
behind. 


Upper  fragment  of  femur.  — - 


Lower  fragment  "i  femur. 1 


Patella. 


Fig.  420.— Transverse  fracture  of  the  femur  in  the  lower  third  with  backward  displacement 
i>i  both  fragments.     Lateral  view. 


those  of  old  age.  (a)  Fourteen  cases  occurred  in  childhood,  the 
ages  averaging  seven  and  a  half  years.  Patients  were  heard  from 
or  reported  for  examination  one  and  a  half  to  seven  years  after  Un- 
original injur)'.  All  cases  were  treated  by  bed  extension,  coap- 
tation splints,  and  the  plaster  spica  to  thigh  and  hip.     All  have  per- 


PROGNOSIS 


303 


feet  functional  results.  Four  cases  mention  slight  pain  occasion- 
ally. Three  of  these  four  cases  have  a  little  stiffness  of  the  knee 
upon  the  injured  side  one  and  a  half  years  after  the  accident,  three 
and  a  half,  and  three  years  respectively.  (If)  Sixteen  cases  oc- 
curred in  adults  whose  ages  ranged  from  eighteen  to  forty-eight 
years.  These  were  seen  or  reported  from  one  to  six  years  after  the 
original  injury.  Five  of  these  have  unqualifiedly  perfect  results, 
without  pain  or  stiffness.  The  remaining  eleven  cases  have 
limited   knee-joint  movement,   aching   in    the    thigh,   pain  after 


-  Upper  fragment. 


1 Lower  fragment. 


Fig.  421. — Same  as  figure  420.     Anteroposterior  view,  showing  lateral  displacement. 


Fig.  422. — Diagram  of  double  inclined  plane  for  fractures  near  the  lower  end  of  the 
femur.  Secures  good  position  through  relaxation  of  gastrocnemius  muscle  and  pads  beneath 
lower  fragment. 


exercising,  pain  in  wet  weather,  weakness  in  the  whole  leg,  and 
slight  lameness  in  walking.  (c)  Five  cases  occurred  during  old  age. 
The  patients  averaged  fifty-eight  years.  These  were  seen  or 
reported  from  two  to  six  years  after  the  original  injury.  None 
has  functionally  perfect  results.  There  is  one  case  of  nonunion 
of  the  thigh  with  shortening  of  the  limb.  Two  cases  must  use  a 
cane  in  walking.  The  knee  is  painful  and  motion  is  limited  in 
all  cases.  Swelling  of  the  leg  is  not  uncommon,  and  pain  in 
wet  weather  is  very  commonly  complained  of  by  these  old 
people. 


304 


FRACTURES    OF    THE    FEMUR 


Considering  these  reported  cases  individually  and  grouped 
according  to  the  three  age  periods,  it  seems  reasonable  to  con- 
clude that  they  form  a  basis  for  a  fairly  accurate  judgment  as  to 
the  probable  outcome  of  these  injuries  to  the  shaft  of  the  femur. 
As  the  age  increases  the  liability  to  impairment  of  the  function 
of  the  limb  increases.  This  liability  is  very  great  after  fifty 
years  are  passed. 


Fig.  423.— Fracture  of  the  thigh.  Con- 
valescent ambulatory  splint  without  trac- 
tion. 


Fig.  424. —  Fracture  of  the  thigh.  Con- 
valescent ambulatory  splint  without  trac- 
tion. Coaptation  splints  may  be  applied  lo 
the  thigh  and  held  by  straps  inclosing  the 
splint. 


It  is  not  very  uncommon,  even  in  closed  fractures  of  the  femur, 
to  find  gangrene  of  the  leg  developing  because  of  laceration  or 
pressure  upon  the  great  vessels  of  the  limb.  Early  amputation  of 
the  thigh  just  above  the  fracture  will  be  necessary  in  these  cases. 
It  should  be  done  earl}-  in  order  to  Save  life.  In  the  aged  the 
shock  of  the  accident  may  prove  fatal.      In  open  fractures  the 


TREATMENT    IN    CII I  I.IJIIOOD 


305 


■S 


violence,  usually  direct,  has  been  so  great  that  the  soft  parts 
about  the  knee  and  throughout  the  whole  thigh  have  been 
greatly  torn  and  lacerated  on  either  side  of  the  fractured  bone. 
The  shock  in  these  cases  is  severe.      Recovery  is  always  doubtful. 

Fracture  of  the  Thigh  in  Childhood. — This  is  usually  caused 
by  direct  violence.  The  fracture  is  often  incomplete.  The 
symptoms  are  those  of  the  same  fracture  in  the  adult.  The  effu- 
sion into  the  knee-joint  is  seen  perhaps  more  uniformly  than  in 
the  adult.  This  effusion  disappears  from  the  child's  knee-joint 
more  quickly  than  from  the  adult  knee-joint. 

Treatment. — After  reducing  the  fracture, — making  the  incom- 
plete fracture   complete  if  perfect  reduction  can   not  be  accom- 
plished in  any  other  way, — the   problem  of 
maintaining  the  reduction  arises.  D 

In  children  of  ten  years  and  older  it  is  pos- 
sible to  use  the  Buck's  extension.  A  plaster- 
of- Paris  spica  splint  from  the  calf  of  the  leg 
to  the  axilla  is  also  a  possible  method  of  im- 
mobilization. 

In  children  under  ten  years  of  age  the  Cabot 
posterior  wire  frame  with  coaptation  splints  and 
extension  is  the  very  best  method  of  conven- 
iently and  efficiently  treating  a  fractured  thigh 
or  fractured  hip. 

The  Cabot  Posterior  Wire  Splint  (see  Fig. 
425)  :  The  splint  consists  of  two  portions — 
a  body  part  and  a  leg  part.  The  patient  lies 
upon  the  body  part  with  the  thigh  and  leg 
resting  upon  the  leg  part,  as  upon  a  coapta- 
tion splint.  Having  a  vise  and  simple  iron 
wire  the  size  of  an  ordinary  lead-pencil,  this  splint  can  be 
made  in  a  kw  moments  ;  the  bending  of  the  wire  according 
to  the  diagram  and  fastening  the  free  ends  by  a  strip  of  small- 
sized  wire  being  all  that  are  required.  It  is  necessary  to  make 
the  following  measurements  before  bending  the  wire  to  the  gen- 
eral shape  shown  in  the  diagram — namely,  D  E,  the  distance 
from  the  axilla  to  the  calf  of  the  leg  ;  A  D,  the  width  of  the 
trunk  ;  A  B,  from  the  axilla  to  a  point  midway  between  the  crest 
20 


Fig.  425.  —  Cabot 
wire  splint  for  fracture 
of  the  hip  and  thigh. 


306  fractures  of  the  femur 

of  the  ilium  and  the  top  of  the  great  trochanter  ;  F  E,  the  width 
of  the  leg,  usually  from  two  to  two  and  a  half  inches.  A  D  and 
B  C  are  bent  to  the  curve  of  the  back.  B  C  is  so  bent  that  it 
jumps  over  the  sacrum  and  does  not  touch  posteriorly  excepting 


Fig.  426. — The  Cabot  wire  splint  ready  for  use.     Lateral  view,  showing  curves  of  splint  cor- 
responding to  small  of  back,  buttock,  and  knee. 


FiK-  127. — The  Cabot  wire  splint  ready  for  use.     Front  view,  showing  covering  of  Canton 
flannel  and  Canton-flannel  double  swathe  for  fixation  to  chest. 

at  B  and  C.  The  long  rods  are  so  bent  as  to  adapt  them  to  the 
posterior  curves  of  the  buttock,  thigh,  popliteal  space,  and  leg 
(see  Fig.  426).  The  splint  is  covered,  as  in  the  posterior  wire 
splint  for  the  leg,  by  layers  of  sheet  wadding  and  cotton  ban- 
dages.     A   swathe  is  attached  to  the  two  sides  A  B  and  D  1 1  of 


TREATMENT  IN  CHILDHOOD 


307 


the  body  part  (see  Figs.  425  and  427).  The  child  is  carefully  laid 
upon  this  splint,  the  body  swathes  adjusted,  the  extension  strips 
applied,  traction  made  by  weight  and  pulley  with  the  foot  of  the 
bed  elevated,  coaptation  splints  applied  and  held  in  position  by 
straps  that  include  the  posterior  wire  splint.  If  it  is  necessary 
to  move  the  child  for  the  making  of  the  bed,  for  the  use  of  the 
bed-pan,  or  for  bathing,  the  extension  may  be   unfastened  tern- 


Fig.  428. — Bradford  bed-frame  for  fixation  of  trunk  in  fracture  of  the  thigh. 


Fig.  429. — Fracture  of  thigh  in  a  child.  Bradford  frame.  Vertical  suspension  of  leg  with 
weight  and  pulley.  Coaptation  splints  to  thigh  and  fixation  of  pelvis  by  towel  swathe  about 
frame. 


porarily  without  any  injury  to  the  fracture,  particularly  if  the  co- 
aptation splints  are  then  temporarily  tightened  to  secure  a  firmer 
hold  on  the  thigh.  The  child  should  be,  of  course,  clean  from 
both  urine  and  feces,  and  the  fracture  immobilized. 

After  four  weeks  of  bed-treatment  the  child  ma)'  be  up,  with 
crutches  and  a  high  shoe  with  the  Cabot  splint  applied.    Shoulder- 


;o8 


FRACTURES    OF    THE    FEMUR 


straps  should  be  attached  to  the  splint  when  it  is  worn  in  the 
erect  position.  This  is  one  of  the  simplest,  cleanest,  and  most 
efficient  methods  of  treating  fracture  of  the  thigh  in  young  chil- 
dren. The  child  can  be  moved  with  freedom  and  without  pain. 
A  light  plaster-of- Paris  spica  bandage  may  be  used  in  convales- 
cence with  crutches  and  a  high  shoe  on  the  uninjured  side. 

In  very  small  children    it  is  sometimes  wise  to  use  the  Brad- 
ford (see  Fig.  428)  frame  and  vertical  suspension  (see  Fig.  429) 


Fig.  430. — Old  fracture  of  tlic  thigh  with  deformity.     Due  to  use  of  unprotected  thigh  hefore 
complete  consolidation  of  fracture  (Warren). 


of  one  or  both  thighs.  This  is  an  efficient,  comfortable,  and 
clean  method  of  treatment.  The  Bradford  frame  is  an  iron,  frame- 
like stretcher,  on  which  the  child  lies  and  to  which  the  shoulders 
and  hips  are  fastened  to  prevent  the  child's  moving  about. 
Counterextension  is  then  secured  by  the  immobilization  of  the 
pelvis  and  hip.  The  extension  is  applied  to  the  thigh  and  leg  as 
usual.  The  limb  is  flexed  on  the  body  to  a  right  angle,  coapta- 
tion splints  being  applied  to  the  thigh.     After  the  novelty  of  the 


SEPARATION    OF    THE    LOWER    KIMHIYSIS 


309 


position  passes  away,  the  child  is  perfectly  contented.  As  soon 
as  union  is  firm,  the  permanent  plaster  spica  dressing  may  be 
applied,  and  the  patient  may  be  up  and 
about  with  high  shoe  upon  the  well  foot 
and  with  crutches.  The  use  of  the  long 
hip-splint  will  be  of  great  service  in  these 
cases  either  with  or  without  the  exten- 
sion foot-piece  (see  Figs.  423,  424).  After 
fracture  of  the  shaft  of  the  femur  in  chil- 
dren there  should  be  no  shortening  and 
no  special  difficulty  in  convalescence. 
It  is  wise  to  guard  the  thigh  a  sufficient 
time  after  union  is  firm  to  insure  absolute 
solidity  and  freedom  from  bowing  in  any 
direction  (see  Fig.  430). 

The  Making  of  the  Bradford  Frame. — 
It  is  most  easily  made  from  ^3 -to  J^-inch 
gas  piping.  It  should  be  one  inch  wider 
than  the  width  of  the  hips,  and  six  inches 
longer  than  the  height  of  the  child.  It 
should  be  covered  with  canvas,  so  as  to 
leave  a  space  under  the  buttocks  for  the 
use  of  the  bed-pan. 


SEPARATION    OF    THE  LOWER  EPIPH- 
*  YSIS  OF  THE  FEMUR 

Anatomy. — The  lower  epiphysis  of 
the  femur  is  the  largest  of  the  epiphyses. 
It  unites  with  the  shaft  of  the  bone  at  or 
about  the  twenty-first  year.  The  epiph- 
ysis includes  the  whole  of  the  articular 
surface  of  the  lower  end  of  the  femur. 
The  points  of  origin  of  the  gastrocnemii 
muscles  are  situated  upon  the  epiphysis  ; 

a  few  fibers  only  arise  from  the  diaphysis.  The  inner  condylar 
line  of  the  femur  is  continuous  with  the  inner  lip  of  the  Iinea 
aspera,    and    terminates    at    the   adductor  tubercle,    which    can 


I 


V 


\ 


Fig.  431. — Femoral  epiph- 
yses at  fifteen  years.  Note  re- 
lations of  lower  epiphyseal  line 
to  inferior  articular  surface. 


3io 


FRACTURES    OF    THE    FEMUR 


be  palpated  upon  the  inner  side  of  the  thigh  near  the  knee- 
joint.  The  upper  and  outer  angle  of  the  trochlear  surface 
of  the  femur  can  be  palpated  best  with  the  knee  flexed.  A  line 
drawn  from  this  angle  of  the  trochlear  to  the  adductor  tubercle 
marks  the  level  of  the  lower  epiphysis  of  the  femur  (see  Fig  43 1). 
In  no  position  of  the  knee-joint  are  the  bones  in  more  than  partial 
contact.      This  is  one  of  the  superficial  joints  of  the  body.      The 


Fig.  432.— Case  :  Bov,  eleven  years  of  age.  Separation  of  the  lower  femoral  epiphysis. 
Photograph  taken  four  hours  after  the  injury.  Note  inversion  of  the  limb  ;  fullness  of  lower 
third  of  thigh  posteriorly  ;  fullness  over  head  of  tibia  ;  fullness  in  popliteal  space  (X-ray 
tracing,  Fig.  434,  explains  the  evident  deformity). 


Fig.  433. — Case  same  as  figure  432.     Separation  of  the  lower  femoral  epiphysis  of  the  left  leg. 
Contrast  two  knees  (see  X-ray  tracing,  Fig.  434). 


strength  of  the  joint  lies  in  the  ligaments  and  fasciae  about  it. 
Unlike  the  elbow-  and  hip-joints,  it  does  not  depend  upon  the 
contour  of  the  bones  for  strength.  An  attempt  to  overextend 
and  to  bend  the  knee  laterally  brings  very  great  strain  to  bear 
upon  the  ligaments  that  are  attached  to  the  lower  femoral 
epiphysis.  If  this  strain  is  ot  sufficient  force,  the  epiphyseal 
cartilage  gives  way,  and  the  epiphysis  separates  from  the  shaft 
of  the  femur.      The  common  cause  of  the  accident  is  the  catch- 


SEPARATION    OF    THE    LOWER    EPIPHYSIS 


311 


ing  of  the  leg  or  thigh  in  the  spokes  of  a  revolving  wheel.     The 
accident  most  often  occurs  to  boys  about  ten  years  old  (see  Figs. 

432,  433)- 

The  epiphysis  usually  separates  without  splintering  the  diaph- 
ysis.  The  periosteum  is  stripped  for  a  considerable  distance. 
About  half  the  cases  are  open,  the  end  of  the  diaphysis  pro- 
jecting through  the  skin  of  the  popliteal  space.  The  knee- 
joint  is  usually  unopened.  There  may  be  almost  no  displace- 
ment of  the  fragments.  A  lateral  sliding  of  the  epiphysis  has 
often   been   observed.       One    condyle    has    been    found   in    the 


Diaphysis  of  femur 


.Lower  femoral 
epiphysis. 


-Condyle  of  femur. 

•Upper  epiphysis 
of  tibia. 


-Diaphysis  of  tibia. 
•  Fibula. 


Fig.  434. — Lateral  view.  Case  of  figure  432.  Boy,  aged  eleven  years.  Separation  of  the 
lower  femoral  epiphysis.  Displacement  forward  of  epiphysis  and  backward  of  lower  end  of 
shaft  (see  Figs.  432,  433.     X-ray  tracing). 


popliteal  space,  but  commonly  the  epiphysis  lies  in  front  of  the 
shaft  of  the  femur  with  its  separated  surface  in  contact  with  the 
shaft  (see  Figs.  434,  435,  436).  The  diaphysis  is  displaced  back- 
ward and  downward  into  the  popliteal  space,  because  of  the  pos- 
sible high  attachment  of  the  gastrocnemii  and  the  fracturing  force. 
The  nerves  of  this  region  may  be  pressed  upon  or  lacerated,  and 
this  may  be  the  cause  of  great  pain  attending  the  accident.  The 
popliteal  vessels  may  be  compressed,  stretched,  or  even  ruptured. 
Consequently,  interference  with  the  circulation  may  result.  This 
may  be  moderate  and  temporary,  or  extreme  and  result  in  gan- 


312 


FRACTURES    OF    THE    FEMUR 


grene  of  the  leg.  The  shock  attending  this  accident  is  often  great. 
Suppuration  may  appear  in  closed  separations,  although  it  is  infre- 
quent ;  it  is  much  more  likely  to  appear  in  open  lesions.   Slough- 


Epiphyseal  line. 
Lower  femoral  epiphysis. 


Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


Fig.  435. — Same  case  as  figure  434.     Anteroposterior  view  of  uninjured  knee  in  a  child  eleven 
years  of  age,  showing  epiphysis  in  position  (X-ray  tracing). 


-  Lower  femoral  epiphysis. 

Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


6. — Same  case  as  figure  134.   Anteroposterior  view  of  displaced  lower  femoral  epiphysis 
in  a  boy  eleven  years  old. 

ing  of  the  skin  is  not  unusual  from  bony  pressure.     Gangrene  ot 
the  leg  sometimes  occurs.      Necrosis  of  bone  is  not  unlikely  to 
result,   particularly  if  the  separation  of  the  periosteum  is  great 
Fig.  437)- 


SEPARATION    OF    LOWER     EPIPHYSIS 


313 


Diagnosis. — After  severe  trauma  to  the  region  of  the  knee 
there  are  three  injuries  that  should  be  considered  possible  :  a 
dislocation  of  the  knee-joint,  a  supracondyloid  fracture  of  the 
femur,  or  a  separation  of  the  lower  epiphysis  of  the  femur. 

There  may  be  so  much  swelling  that  a  satisfactory  examina- 
tion is  impossible.  Ordinarily,  careful  palpation  will  detect  the 
bony  outlines  of  a  dislocation.  This  is  extremely  rare  in  children. 
The  crepitus  of  a  supracondyloid  fracture  is  bony  and  hard,  and 
the  displacement  of  the  distal  fragment  into  the  popliteal  space 

Lower  femoral  epiphysis. 


Diaphysis  of  femur. f  — - 


■  Upper  epiphysis  of 
tibia. 


Diaphysis  of  tibia. 


Fig-  437- — Separation  of  lower  epiphysis  of  the  femur  with  displacement  forward  and  upward 
between  femoral  diaphysis  and  patella  (Warren  Museum,  8116-1). 


evident.  All  fractures  at  the  knee  are  not  necessarily  supracondy- 
loid. Several  cases  of  fracture  of  one  condyle  of  the  femur  into  the 
joint  are  reported.  The  separated  epiphysis  itself  may  be  split 
through  into  the  joint.  A  severe  trauma  to  the  knee,  a  cart- 
wheel accident  to  a  young  boy,  attended  by  considerable  shock, 
followed  by  great  swelling  of  the  knee,  a  fullness  in  the  pop- 
liteal space,  feeble  or  absent  pulsation  in  the  dorsalis  pedis  and 
posterior  tibial  arteries,  increased  lateral  and  anteroposterior 
mobility  at  the  knee,  and  soft  crepitus  form  the  picture  charac- 
teristic of  a  separation  of  the  lower  femoral  epiphysis. 


3H 


FRACTURES    OF    THE    FEMUR 


Prognosis. — It  is  impossible  to  state  positively  that  in  any  given 
case  there  will  or  will  not  be  shortening  of  the  leg  upon  the  injured 
side  because  of  a  cessation  of  growth  in  the  femoral  epiphysis.  If 
the  epiphysis  is  separated  without  great  laceration  and  periosteal 
denudation  and  is  replaced  soon  after  the  injury,  the  chances  are 
that  there  will  be  a  minimum  amount  of  shortening  of  the  affected 
leg.  After  open  incision  and  replacing  of  the  epiphysis  in  closed 
fractures  good  results  are  to  be  expected  as  far  as  the  useful- 
ness of  the  joint  is  concerned.      Slight  necrosis  of  bone  may 


Fig.  438. — Method  of  grasping  knee  to  reduce  a  displaced  femoral  epiphysis.     Note  thumbs 
at  anterior  border  of  epiphysis  and  fingers  upon  the  lower  end  of  the  femoral  diaphysis. 


attend  convalescence.  If  the  separation  is  closed  and  reduction 
is  impossible  by  manipulation  alone,  open  incision  should  be 
made. 

Treatment. — If  the  vessels  arc  torn  ;  if  there  is  great  laceration 
of  the  soft  parts,  amputation  should  be  performed.  If  the  sepa- 
ration is  open  and  the  shaft  of  the  femur  protrudes  through  the 
wound,  and  much  of  the  diaphysis  is  seen  to  be  denuded  of 
periosteum,  the  diaphysis  should  be  resected  to  the  limit  of  peri- 
osteal separation,  and  then  the  bone  reduced.      It  may  be  neces- 


SEPARATION    OF 


"HE    LOWER    EPIPHYSIS 


315 


sary  to  enlarge  the  opening  in  the  soft  parts  before  it  is  possible 
to  reduce  the  bone.  If  the  separation  is  closed,  reduction  by 
manipulation  should  be  attempted  :  if  successful,  the  leg  should 
be  flexed  to  a  right  angle  or  an  acute  angle  and  immobilized  in 
a  plaster-of-Paris  splint. 

Reduction  by  Manipulation  When  the  Fragment  is  Dis= 
placed  Forward. — While  an  assistant  makes  traction  upon  the 
leg,  the  surgeon,  grasping  the  thigh  above  the  condyles  with  the 


Fig.  439. — Diagram  to  show  method  of  reduction  of  separated  femoral  epiphysis  by  incision. 
Retractors  are  upon  diaphysis  and  epiphysis,  and  lines  of  traction  are  shown  by  arrows. 


Fig.  440. — Cabot  splint  arranged  as  double  inclined  plane  for  epiphyseal  separation  at  the 
lower  end  of  femur.  B,  The  part  behind  the  knee-joint,  may  be  bent  to  a  more  acute  angle  ; 
C,  the  body  portion,  is  to  be  molded  to  the  trunk  ;  A,  the  foot-piece.  With  the  angle  at  B 
obliterated,  the  splint  may  be  used  for  fracture  of  the  leg  in  childhood. 


fingers  in  the  popliteal  space,  making  pressure  on  the  upper 
fragment,  pushes  with  his  two  thumbs  upon  the  upper  border 
of  the  displaced  epiphysis  (see  Fig.  438).  The  leg  is  gradually 
flexed.  If  the  reduction  is  achieved,  a  soft  grating  sensation  will 
have  been  felt,  and  the  shortening  of  the  leg  that  existed  pre- 
vious to  reduction  will  disappear.  The  contour  of  the  knee  will 
assume  a  somewhat  normal  appearance. 

The  Operative  Method   of   Reduction. — The    obstacle   to  re- 


i6 


FRACTURES    OF    THE    FEMUR 


duction  is  no  single  band  or  obstruction,  it  is  the  retraction  and 
tension  maintained  by  the  fasciae,  ligaments,  and  muscles  of  the 
thigh  upon  the  tibia.  This  retraction  is  so  great  that  the  tibia  is 
held  crowded  against  the  lower  end  of  the  upper  fragment,  and 
prevents  the  replacing  of  the  epiphysis.  An  incision  is  best 
made  over  the  denuded  shaft  of  the  femur  on  the  outer  side  of 
the  leg.  The  shaft  and  the  epiphysis  are  exposed  in  the  wound. 
Traction  should  be  made  by  means  of  periosteal  retractors  upon 
the  epiphysis,  and  countertraction  upon  the  diaphysis  while  the 
leg  is  slowly  flexed  from   the   completely  extended  position,  as 


Fig.  441. — Case:  Boy,  aged  eleven  years.  Separation  of  left  lower  femoral  epiphysis  ;  in- 
cision, reduction.  Recovery.  After  six  months,  useful  leg.  Knee  motion  in  flexion  beyond 
a  right  angle  as  shown  (see  frontispiece  and  Figs.  432-437  inclusive). 


indicated  in  the  figure  (see  Fig.  437).  This  will  result  in  the 
reduction  of  the  displacement.  Suture  of  the  bones  may  be 
needed  to  retain  the  replaced  epiphysis  in  position.  The  flexed 
position  of  the  leg  will  assist  materially  in  retaining  the  fragment 
in  position.  The  application  of  a  light-weight  plaster-of-Paris 
circular  bandage  from  the  toes  to  the  groin,  with  the  leg  flexed 
to  a  right  angle,  will  immobilize  the  parts. 

After-union  is  firm  between  the  epiphysis  and  shaft.  After 
three  or  lour  weeks  the  leg  may  be  gradually  extended.  The 
foot  of  the  injured  leg  may  be  touched  to  the  floor  while  the 
plaster  splint  is  in  place  about  five  weeks  after  the  injury.      Slight 


SEPARATION    OF    THE    LOWER    EPIPHYSIS  317 

weight  may  be  borne  upon  it.  The  plaster  should  be  removed 
after  about  six  weeks,  and  gentle  active  and  passive  motion  made 
at  the  knee-joint.  Massage  to  the  calf  of  the  leg  and  the  thigh 
should  be  given  daily.  A  flannel  bandage  applied  to  the  foot, 
ankle,  leg,  and  thigh  will  be  all  the  support  that  is  needed. 
After  about  ten  weeks  the  boy  should  be  allowed  to  step  on  the 


Fig.  442. — Case  same  as  that  in  figure  441.  Separation  of  lower  femoral  epiyhysis.  Note 
degree  of  extension  possible  and  cicatrix  of  incision  six  months  after  operation.  Note  also 
absence  of  deformity. 

foot  all  he  chooses.  At  first  he  will  do  this  with  fear,  but  soon 
with  confidence.  There  will  usually  be  a  little  limitation  of 
motion  in  the  knee-joint  (see  Figs.  441,  442). 

Traumatic  Gangrene,  Septicemia,  Malignant  Edema. — Frac- 
tures complicated  with  laceration  of  the  large  vessels  are  a  fre- 
quent cause  of  gangrene.      If  an  acute   infectious  process  starts 


3 18  FRACTURES    OF    THE    FEMUR 

in  a  limb  with  traumatic  gangrene,  the  gangrene  spreads  with 
frightful  rapidity.  The  general  disturbance  is  very  great.  A 
septicemia  of  grave  type  results.  To  such  cases  in  which  there 
is  much  gas  formation,  associated  with  edema,  and  which  result 
in  rapid  destruction  of  tissue,  the  name  malignant  edema  is  given. 
The  specific  bacillus  of  malignant  edema  will  be  discovered  in  the 
blood  and  tissues  far  above  the  wound  of  the  soft  parts. 

The  proper  treatment  is  early  high  amputation  with  stimu- 
lation of  the  heart  by  strychnin  and  alcohol. 

Fat  Embolism. — Fat  embolism,  to  a  greater  or  less  degree,  ex- 
ists in  every  case  of  fracture.  It  is  most  evidently  present  in  those 
cases  associated  with  great  laceration  of  tissue  and  in  open  frac- 
tures. The  soft  fat  of  the  medullary  tissue  is  the  source  of  the 
fat-drops  that,  getting  into  the  venous  circulation,  are  carried 
directly  to  the  pulmonary  capillaries,  where  they  lodge  unless 
the  blood  pressure  is  sufficient  to  force  them  out  of  the  lung 
capillaries  on  into  the  systemic  circulation.  They  then  lodge  in 
the  brain,  kidneys,  or  other  organs.  The  danger  in  fat  embol- 
ism is  that  the  patient  may  die  from  asphyxiation,  due  to  the 
imperfect  oxygenation  of  the  blood  because  of  the  rapid  occlu- 
sion of  the  pulmonary  capillaries  with  fat  globules. 

Symptoms. — Symptoms  develop  within  twenty-four  to  seventy- 
two  hours  after  the  accident.  In  fatal  cases  facial  pallor  and  dis- 
tress are  followed  by  cyanosis.  The  patient  is  first  excitable, 
restless,  then  somnolent  and  comatose.  Death  occurs  from 
asphyxia. 

The  temperature  is  usually  not  elevated.  Respiration  is  rapid. 
Hemoptysis  may  exist,  associated  with  pulmonary  edema.  Fat 
globules  will  be  found  in  the  urine,  for  they  are  eliminated  by 
the  kidney. 

A  difficulty  in  breathing,  cyanosis,  and  fat  found  in  the  urine 
maybe  the  only  evidences  of  a  fat  embolism.  The  prognosis  is, 
of  course,  dependent  upon  the  extent  of  the  embolism  and  the 
strength  of  the  heart. 

Treatment. — Stimulation  of  the  heart  for  its  extra  work  is 
indicated.  Immobilization  of  the  fractured  part  to  prevent  more 
fat  from  getting  into  the  circulation  and  the  administration  of 
oxygen  to  relieve  asphyxia  are  important  in  the  treatment. 


CHAPTER  XIII 
FRACTURES  OF  THE  PATELLA 

Anatomy. — A  knowledge  of  the  anatomical  relations  of  the 
patella  is  necessary  to  a  perfect  understanding  of  the  fractures  to 
which  it  is  liable  (see  Fig.  443).      Attached  to  the  patella  upon  its 


—V 


Fig.  443. — Normal  patella:  i,  From   in   front;    2,  from  behind;  3,  from  inner  side;   4,  from 
outer  side  ;  5,  anteroposterior  section  ;  a,  b,  usual  seat  of  fracture. 


Patella. 


Synovial  membrane, 
cavity  of  joint. 

Femur. 


W0& 


vw 


Fig.  444. — Horizontal  frozen  section  of  the  knee-joint,  showing  lateral  extent  of  synovial 
membrane  (Professor  Dwight's  specimen). 


upper  border  is  the  tendon  of  the  quadriceps  extensor  muscle. 
Upon  each  side  of  the  bone  are  attached  the  vastus  interims  and 
vastus  externus  respectively.  Below  the  insertions  of  the  vasti 
is  a  portion  of  the  low  attachment  of  the  fascia  lata  of  the  thigh. 

3*9 


320 


FRACTURES  OF  THE  PATELLA 


At  the  lower  border  of  the  patella  is  the  patellar  tendon.      This 
tendon  is  inserted  into  the  tubercle  of  the  tibia,  and  it  is   sepa- 


Fig.  445. — Anteroposterior  frozen  section  of  the  knee-joint,  showing  extent  of  synovial  mem- 
brane superiorly  and  inferiorly  (Professor  Dwight's  specimen). 


Fig.  446. — Ligamentous  preparation  of  the  knee,  the  patellar  tendon  cut  just  belowjthe 
patella,  dissected  out,  and  reflected  downward.  Shows  the  lateral  expansions  of  the  quadri- 
ceps tendon  extending  to  the  tibia  I  from  dissection  by  Professor  Dwight). 


rated  from  the  head  of  the  tibia  by  a  bursa  and  a  pad  of  fat 
tissue.  The  tendon  of  the  quadriceps,  the  insertions  of  the  vasti 
muscles,    and   the  patellar    tendon    are   all    continuous   with  the 


Fig.  447.— Skiagraph  of  normal  right  knee-joint  in  an  adult. 


321 


322 


FRACTURES  OF  THE  PATELLA 


strong  fascia  lata  surrounding  the  thigh.  The  fascia  lata  is 
attached  below  to  the  condyles  of  the  femur,  the  sides  of  the 
patella,  the  tuberosities  of  the  tibia,  the  head  of  the  fibula,  and 
to  the  deep  fascia  of  the  leg  in  the  popliteal  space.  The  patella 
is  seen,  therefore,  to  lie  in  a  strong  fibrous  sheath  that  encircles 
the  knee  and  is  attached  to  various  bony  prominences  (see  Figs. 


Fig.  448. — A,  Nearly  median  section  of  the  knee-joint,  the  convex  surfaces  of  the  femur 
and  of  the  patella  in  contact.  A,  Diagrammatic  view,  showing  position  in  which  the  patella 
is  subjected  to  a  strain  on  contraction  of  the  quadriceps,  the  probable  mechanism  of  many 
patellar  fractures. 


444,  445,  446).  The  synovial  membrane  of  the  knee-joint  lies 
directly  beneath  and  attached  to  the  posterior  surface  of  the 
patella.  Laterally  and  posteriorly  the  synovial  membrane  lies 
next  to  the  encircling  fascia  of  the  joint.  The  deep  bursa  of  the 
femur  lies  in  front  of  the  lower  end  of  the  femur  beneath  the 
quadriceps  muscles,  and  often  communicates  with  the  knee-joint. 


MMI'TOMS 


323 


The  tubercle  of  the  tibia  is  on  a  level  with  the  head  of  the  fibula. 
The  outline  and  anterior  surface  of  the  patella  can  be  palpated 
throughout.  When  the  leg  is  completely  extended  and  is  at 
rest,  the  patella  can  be  moved  from  side  to  side.  The  numerous 
longitudinal  striae  on  the  anterior  surface  of  the  patella  can  be 
detected.  In  these  the  tendinous  bundles  of  insertion  of  the 
rectus  are  embedded.  It  is  these  fibers  that  fold  in  over  the 
broken  patella  and  prevent  the  approximation  of  the  fragments. 
The  ligament  of  the  patella  is  parallel  with  the  axis  of  the  leg. 

Fracture  of  the  patella  occurs  through  either  muscular  con- 
traction (see  Fig.  448)  and  strain  or  through  direct  violence. 
The  form  0/  the  fracture  is  not  altogether  dependent  upon  the 


Skin. 
Quadriceps  fascia. 


Skin. 


Ligamentum  patellse. 
Skin. 


Synovial  membrane  with  under- 
lying fat  tissue. 


Joint  surface  of  patella. 


Point  of  reflexion  of  synovial 
membrane. 


Fig.  449. — Diagram  of  anteroposterior  section  of  patella  and  tendons,  showing  the  small 
extrasynovial  portion  of  posterior  surface  of  the  bone. 


causative  force.  The  fracture  will  be  either  transverse  and  clean 
cut  or  comminuted  and  irregular.  The  knee-joint  is  generally 
opened  :  i.  e.,  the  synovial  membrane  is  generally  torn.  The 
synovial  membrane  is  reflected  from  the  posterior  surface  of 
the  patella  some  distance  from  the  most  inferior  tip  of  the  bone. 
It  is  possible,  therefore,  for  a  fracture  to  occur  at  the  lower  por- 
tion of  the  bone  for  some  considerable  distance  from  the  lower 
edge  without  opening  the  knee-joint  (see  Fig.  449). 

Symptoms. — There  are  pain  in  the  knee  and  immediate  dis- 
ability, varying  from  partial  to  complete  loss  of  power  in  ex- 
tension and  in  flexion.  The  patient  may  be  unable  to  rise  or,  it 
he  can  stand,  he  can  not  move  except  backward,  and  then  only 


324  FRACTURES  OF  THE  PATELLA 

by  dragging  the  foot  of  the  injured  limb  upon  the  ground.  The 
patient  is  often  unable  to  raise  the  heel  from  the  bed  when  lying 
upon  the  back.  Swelling  of  the  knee,  which  at  first  is  slight, 
after  three  or  four  hours  may  become  very  great  (see  Fig. 
450).  The  swelling  is  due  to  the  accumulation  of  blood  and 
synovial  fluid  in  the  knee-joint.  A  traumatic  synovitis  exists. 
Immediately  after  the  accident  crepitus  may  be  elicited  by 
pressing  the  two  fragments  together.  When  the  knee-joint 
is  distended  by  fluid,  it  is  often  impossible  even  to  detect  the 
fragments  of  the  patella,  but  as  the  fluid  subsides  and  the  sulcus 
between  the  bones  is  felt,  crepitus  can  again  be  detected.  The 
degree  of  the  separation  of  the  fragments  is  dependent  upon  the 


Fig.  450. — Case  :    Ri^ht  knee  normal ;  left  knee,  fracture  of  patella.    Two  days  after  accident. 
Observe  swelling  of  whole  knee.    Joint  filled  with  fluid. 


amount  of  distention  of  the  joint  and  upon  the  extent  of  the 
tearing  of  the  lateral  aponeurosis  (fascia  lata)  of  the  knee,  per- 
mitting muscular  contraction  and  retraction.  If  the  causative 
violence  is  associated  with  a  wound  of  the  soft  parts,  there  will 
be  evident  a  contusion  or  an  abrasion  of  the  skin  or  a  lacerated 
wound  opening  the  knee-joint,  making  the  fracture  an  open  one. 

Treatment. — The  indications  to  be  met  arc  the  limitation  and 
removal  of  the  effusion,  the  reduction  of  the  fragments,  the  main- 
tenance of  the  reduction  until  union  is  satisfactory,  and  the  res- 
toration of  the  functions  of  the  joint  to  its  normal  condition. 

The  Limitation  and  Removal  of  the  Effusion. —  If  the  frac- 
ture   is    seen    before:    there    is    great    swelling,    limitation    of    the 


EX  PECTANT    TKEAT.M  ENT 


5*3 


swelling  may  be  effected  by  immobilization  of  the  knee  and  the 
accurate  application  of  an  elastic  rubber  bandage.      If  the  ban- 


Fig.  451.— Fracture  of  patella;  fibrous 
union.  Broadening  of  lower  fragment 
(Warren  Museum,  specimen  3652). 


Fig.  452. — Fracture  of  patella.  Fibrous 
union  with  moderate  separation;  marked 
tilting  forward  of  fragments  ;  no  enlarge- 
ment of  fragments.  View  from  side,  a. 
Fibrous  union;  6,  extent  of  articular  sur- 
face whicli  is  now  concave  (Warren  Muse- 
um, specimen  1129). 


Fig.  453.— Fracture  of  patella;    union  with  long  fibrous  band;    separation  of  fragments  z?i 
inches  (Warren  Museum,  specimen  5253). 


dage  is  not  at  hand,  sponge  compresses  may  be  used — viz.,  two 
slightly  moistened  bath  or  carriage  sponges  are  allowed  to  dry 
under  pressure  sufficient  to  flatten  them.      These  are  placed  upon 


126 


FRACTURES.  OF    THE    PATELLA 


each  side  of  the  knee  and  over  it,  and  are  held  by  a  few  turns  of 
a  roller  bandage.  Cool  water  is  then  poured  over  the  whole. 
As  the  sponges  absorb  the  water  they  enlarge,  causing  equable 
and  firm  pressure  on  the  knee,  thus  very  materially  hindering  the 
accumulation  of  fluid  and  favoring  its  absorption.  These  wet 
sponge  compresses  should  be  left  in  position  for  from  twelve  to 
twenty-four  hours,  and  then  a  fresh  set  used. 


Fig.  454. — Fracture  of  patella  ;  bony 
union;  some  elongation  of  bone  as  a  whole. 
View  from  side  (Warren  Museum,  speci- 
men 6707). 


Fig.  455.  — Recent  fracture  of  patella 
with  comminution.  Probably  from  direct 
violence  (Warren  Museum,  specimen  1130). 


Fig.  456. — Ham-splint  without  strap, 
showing  proper  length  ami  relation  to 
thigh  and  leg  posteriorly. 


Massage  skilfully  applied  to  the  whole  limb,  irrespective  of  the 
method  of  treatment  eventually  instituted,  will  not  only  assist  in 
the  absorption  of  the  fluid,  but  will  preserve  intact  the  muscles 
of  the  limb.  Massage  to  be  effective  should  be  applied  at  least 
twice  daily,  and  from  fifteen  minutes  to  half  an  hour  at  a  time. 
Slight  pain  will  be  felt,  but  after  a  time  massage  will  be  painless 
and  give  great  comfort. 


EX  I'ECTANT    TKEATM ENT 


327 


The  Reduction  of  the  Fragments. — No  attempt  should  be 
made  to  reduce  the  fragments  until  nearly  all  the  fluid  is  removed 
from  the  knee-joint.  Reduction  is  accomplished  by  immobiliza- 
tion of  the  knee-joint,  by  fixation  of  the  lower  fragment,  and  by 
traction  upon  and  fixation  of  the  upper  fragment.  The  leg 
should  be  extended  completely  and  the  knee  immobilized  either 


Fig.  457. — Improper  method  of  applyng  a  ham-splint.     The  knee-joint  is  not  immobilized. 
Flexion  is  possible.     Straps  1  and  2  are  insufficient. 


Fig.  458. — Proper  method   of   applying  a  ham-splint.     The  third  adhesive-plaster  strap  (3) 
prevents  flexion  of  the  knee. 


upon  a  ham-splint  (see  Figs.  456,  457,  458)  or  upon  a  Cabot 
posterior  wire  splint.  The  ham-splint  is  preferably  made  from 
a  plaster-of-Paris  bandage.  The  lower  fragment  is  held  fixed 
by  a  strap,  preferably  of  adhesive  plaster,  placed  obliquely  about 
the  leg  and  splint,  and  fastened  to  the  splint  above  the  fragment 
(see  Figs.  459,  460,  461,  462).  The  upper  fragment  is  drawn 
down  first  by  elevation  of  the  leg  upon  an  inclined  plane, 
which   relaxes  the   quadriceps  extensor  muscle,   then    by  trac- 


328 


FRACTURES    OF    THE    PATELLA 


tion  obtained  by  a  strap  passed  obliquely  above  the  upper  frag- 
ment and  fastened  to  the  splint  below  the  fragment.  The 
upper  strap  will  need  repeated  adjustment  as  the  plaster  slips 
and  as  the  fluid  disappears  from  the  joint.      To  facilitate  trac- 


Fig.  459.— Expectant  method  of  treating  fracture  of  the  patella.  Leg  extended  on  pos- 
terior wire  splint.  Fragments  held  by  two  straps.  Fluid  has  left  the  joint.  A,  Side  splints; 
B,  coaptation  splints  reflected. 


Fig.  460.—  Expectant  method  of  treating  fracture  of  the  patella.    Same  as  figure  459.  with  the 
addition  of  coaptation  splints  to  the  thigh,  padding,  and  straps. 


tion  by  this  upper  strap,  the  quadriceps  muscle  should  be 
held  firmly  by  coaptation  splints  and  straps  encircling  the  pos- 
terior splint.  The  quadriceps  can  not  then  actively  pull  upon 
the   upper  fragment.     The  tendency  of   these  two  straps  thus 


EX  PECTANT    TREATMENT 


129 


applied  will  be  to  tilt  the  broken  surfaces  of  the  two  fragments 
upward  and  apart,  particularly  if  there  is  fluid  in  the  joint.  It  is 
important,  therefore,  to  place  a  third  strap  over  the  two  broken 
edges  of  the  fragments,  in  order  to  hold  them  down  to  their 
proper  level  and  to  assist  in  bringing  them  into  apposition.  The 
coaptation  splints  should  be  removed  at  every  massage  treat- 
ment, the  upper  fragment  being  steadied  by  an  assistant.  The 
straps  about  the  patella  need  not  be  removed  during  the  mas- 
sage.     They  will  be  of   no  inconvenience.      As    soon    as    the 


Fig.  461. — Expectant  method  of  treating  fracture  of  the  patella.  Same  as  figure  460,  with 
the  addition  of  two  lateral  splints,  padding,  and  straps.  A  posterior  wooden  splint,  seen 
better  in  figure  460,  and  elevation  of  the  limb. 


effusion  has  left  the  joint,  all  will  have  been  gained  in  the  reduc- 
tion of  the  fracture  that  can  be  gained  by  this  method. 

Aspiration  of  the  knee-joint  by  means  of  a  narrow  knife  inci- 
sion or  by  means  of  a  large-sized  trocar  is,  if  done  under  strictly 
antiseptic  precautions  and  forty-eight  hours  after  the  fracture, 
often  satisfactory  in  immediately  removing  the  bulk  of  the  effu- 
sion ;  if  firm  compression  is  then  made,  it  effectually  prevents 
the  reaccumulation  of  fluid. 

Maintenance  of  Reduction  until  Union  is  Satisfactory. — At 
the  end  of  about  four  or  six  weeks  from  the  injury  union  will  be 
found.      All  fluid  will    have  left  the  joint.      The  retentive  straps 


330 


FRACTURES    OF    THE    PATELLA 


and  coaptation  splints  may  now  be  removed.  The  leg  should 
be  immobilized  by  means  of  a  plaster-of-Paris  splint  extending 
from  just  below  the  swell  of  the  calf  to  the  groin.  This  splint 
is  split  on  the  side  or  posteriorly  and  arranged  as  a  removable 


Fig.  462. — Expectant  method  of 
treating  fracture  of  the  patella.  An- 
terior view  01  apparatus  complete. 
The  padding  of  the  side  splints  is 
shown. 


Fig.  463. — Extent  of  flannel  bandage  to  knee, 
applied  after  all  immobilizing  apparatus  is  re- 
moved.     The  bandage  is  started  at  I. 


dressing.     Proper  bathing  is  facilitated.     This  enables  the  masseur 
to  work. 

The  removable  splint  is  made  thus  :  A  light  weight  plaster-of- 
Paris  roller  bandage  is  applied  to  the  properly  protected  leg  from 
above  the  ankle  to  the  groin.  It  is  split  in  the  median  line 
its   whole   length   before   the  plaster  has   quite  hardened.      It  is 


EXPECTANT    TREATMENT 


331 


sprung  off  the  leg.  After  it  is  hard  a  narrow  strip  of  leather, 
upon  which  are  fastened  lacing  hooks,  is  stitched  to  each  cut 
edge.  This  splint  may  now  be  sprung  on  the  limb  and  laced 
snugly  in  position.  A  leather  splint  may  be  similarly  made 
from  a  plaster  cast  and  mold  of  the  limb.  As  soon  as  union 
is  firm,  the  patient  should  be  up  and  about  with  the  light 
removable  fixation  splint  applied,  walking  with  the  aid  of 
crutches. 

Fixation  (prevention  of  flexion  and  extension)  on  walking  is 
to  be  maintained  for  at  least  six  months  after  the  injury.  Pro- 
tecting the  knee  thus  when  walking  for  this  period  of  six  months 


Fig.  464.— Old  fracture  of  patella  ;  great  separation  of  fragments.  Condyles  of  the  femur 
are  prominent  in  between  fragments.  Leg  was  useful,  but  weak.  A,  The  lower  fragment; 
B,  the  condyles  of  the  femur  ;  C,  the  upper  fragment. 


does  not  preclude  active  movements  of  the  knee  when  not  bear- 
ing weight  upon  the  limb.  At  the  end  of  that  time  the  patient 
may  be  allowed  to  go  about  with  a  cane  and  a  snugly  fitting  roller 
bandage  (see  Fig.  463).  This  bandage  should  be  made  of  medium 
weight  flannel,  cut  straight  with  the  weave  and  not  on  the  bias. 
The  bandage  should  be  applied  from  the  middle  of  the  calf  of 
the  leg  to  the  middle  of  the  thigh  when  the  leg  is  completely 
extended.  As  the  patient  becomes  confident  of  his  strength,  the 
cane  need  not  be  carried.  Sudden  movements  are  to  be  avoided. 
At  the  end  of  eight  or  ten  months,  varying  with  the  individual 
case,  all  support  may  be  omitted  from  the  knee. 


332 


FRACTURES    OF    THE    PATELLA 


The  Restoration  of  the  Function  of  the  Joint. — From  the 
day  of  the  injury  daily  massage  to  the  whole  limb  is  important. 
It  maintains  the  muscles  in  good  tone.  It  prevents  adhesion  of 
the  fragments  to  the  tissues  about  the  condyles  of  the  femur,  a 
not  uncommon  cause  of  ankylosis  of  the  joint.  It  facilitates  the 
absorption  of  the  effusion  of  blood  and  synovial  fluid.  After  the 
fourth  week  daily  passive  motion  is  to  be  instituted  :  at  first 
very  slight  indeed,  barely  two  or  three  degrees.      If  the  relative 


Fig.  465. — Case:  Fracture  of  the  patellfe.    Moderate  separation  of  the  fragments  of  each  knee- 
joint.     Useful  legs. 


position  of  the  fragments  is  not  altered  perceptibly  by  this  pas- 
sive motion  and  lasting  pain  is  absent,  it  may  be  persisted  in  with 
regularly  increasing  amounts.  At  the  expiration  of  eight  or 
ten  weeks  active  motion  at  the  knee-joint  may  cautiously  be 
allowed.  The  appearance  of  persistent  and  increasing  tender- 
ness, sensitiveness,  or  pain,  and  increasing  separation  of  the  frag- 
ments are  the  indications  to  diminish  or  cease  passive  and  active 
motions. 


EXPECTANT    TKEAT.M  ENT 


333 


Summary  of  the  Treatment  of  Fracture  of  the  Patella  by  the 
Expectant  or  Nonoperative  Method. — During  four  weeks  fixa- 
tion of  the  knee,  elastic  compression,  douching,  massage,  the 
thigh  flexed  slightly  on  pelvis,  the  leg  extended,  retentive  straps, 
coaptation  splints,  are  the  measures  employed.  At  the  fourth  or 
sixth  week,  remove  all  apparatus,  apply  removable  splint,  allow 
walking  with  crutches,  and  use  daily  passive  motion.  At  the 
eighth  week,  discard  crutches,  use  cane,  and  permit  limited  daily 
active  motion.     At  the  sixth  month,  discard  splint,  apply  flannel 


Fig.  466. — Fracture  of  upper  third  of  patella,  showing  separation  of  fragments.     Tilting  of  the 
upper  fragment  through  rotation  upon  its  transverse  axis  (X-ray  tracing). 


bandage,  and  discard  cane.     At  the  eighth  to  the  tenth  month, 
remove  all  support. 

Open  Fracture  of  the  Patella. — This  is  a  very  serious  in- 
jury, because  one  of  the  largest  synovial  cavities  of  the  body  is 
exposed  to  infection.  It  is  safest  and  wisest  to  lay  open  the  knee- 
joint,  to  thoroughly  irrigate  it  with  a  solution  of  corrosive  sub- 
limate (1  :  10,000),  and  then  with  a  sterilized  normal  salt  solution. 
All  blood-clots  should  be  carefully  wiped  away.  All  loosely 
attached  fragments  of  bone  should  be  removed.  Particular 
attention  should  be  paid  to  the  posterior  parts  of  the  joint,  behind 


334 


FRACTURES    OF    THE    PATELLA 


the  condyles  of  the  femur.  It  will  be  found  convenient  in  clean- 
ing these  parts  first  to  flush  the  joint  with  sterile  salt  solution 
and  to  flex  and  to  extend  the  knee.  All  parts  of  the  joint  pos- 
teriorly are  thus  likely  to  be  thoroughly  flushed.  The  fragments 
should  be  approximated  and  sutured  by  some  absorbable  suture. 
The  skin-wound  should  be  closed.  The  knee-joint  should  be 
immobilized  in  a  posterior  wire  splint  and  side  splints  or  in  a 
plaster-of- Paris  splint. 


Fig.  467. — Fracture  of  the  patella  in  the 
lower  third,  showing  tilting  of  lower  frag- 
ment through  rotation  on  its  transverse 
axis  (X-ray  tracing). 


Fig.  468. — Fracture  ot  lower  edge  of 
patella.  Little  separation  of  fragments. 
Indirect  violence  (X-ray  tracing). 


Prognosis. — Ordinarily,  an  individual  should  not  follow  his 
occupation  for  about  six  weeks  to  two  months  after  a  fracture  of 
the  patella — /.  e.,  unless  the  occupation  can  be  conducted  with 
a  leg  held  stiffly  at  the  knee.  The  functional  usefulness  of  the 
limb  and  not  anatomical  considerations  should  be  the  chief  crite- 
rion in  determining  the  result  following  fracture  of  the  patella.  If 
a  man  can  earn  his  living  as  before  the  accident  without  local  dis- 
comfort or  hindrance,  he  possesses  a  useful  limb.  It  makes  little 
difference  if  there  is  a  slight  separation  of  the  fragments  or  a  sug- 


PROGNOSIS    AFTER    EXPECTANT    TREATMENT 


-5  ■*>  r* 

333 


gestion  of  a  limp  or  slight  atrophy  of  the  thigh  and  calf  muscles  ; 
these  conditions  are  all  to  be  accepted  as  part  of  the  irreparable 
damage,  and  are  trivial.  In  nonoperative  cases  the  union  is 
usually  fibrous,  although  it  may  be  bony.  The  interval  between 
the  fragments  may  amount  to  five  or  six  inches.  The  approxi- 
mation of  the  fragments  of  the  patella  is  not  evidence  of  strength, 
for  the  fibrous  bond  of  union  may  be  much  narrower  than  the 
fractured  surface  and  very  thin,  and  thus  easily  ruptured.      The 


Fig.  469. — Double  fracture  of  patella  without  great  Fig.   470. — Transverse   fracture  of 

separation  of  fragments  (X-ray  tracing).  patella,  showing  straps  in  position  to 

hold  fragments  (X-ray  tracing). 


usefulness  of  the  limb  after  fracture  of  the  patella  is  not 
dependent  upon  any  one  factor,  either  the  kind  of  union  or 
the  extent  of  the  separation  of  the  fragments  of  bone.  There 
are  usually  no  adhesions  of  the  upper  fragment  to  the  femur  ; 
but  injury  to  the  bursa  under  the  quadriceps  may  cause 
troublesome  adhesions  upon  the  anterior  surface  of  the  thigh. 
Full  flexion  is  a  common  result,  but  there  is  often  limita- 
tion of  active  extension.  There  almost  always  remains  a  little 
joint  stiffness,  despite  both  massage  and  active  and  passive  mo- 


336  FRACTURES  OF  THE  PATELLA 

tion  ;  this,  unless  due  to  fibrous  adhesions,  disappears  gradually. 
The  majority  of  cases  of  fracture  of  the  patella  under  careful 
nonoperative  treatment  will  secure  a  useful  limb.  A  patella 
once  fractured  and  having  united  by  fibrous  or  bony  union  may 
be  broken  through  the  callus  of  the  healed  fracture  or  in  an 
entirely  different  fracture  from  the  first  break. 

Results  after  Fracture  of  the  Patella. — In  a  series  of  forty- 
seven  cases  of  fracture  of  the  patella  treated  at  the  Massachusetts 
General  Hospital,  occurring  between  the  ages  of  eleven  and 
sixty-five  years,  four  were  over  fifty  years,  thirteen  were  under 
twenty-five  years,   twenty-nine  were    between    twenty-five   and 


! 

Fig.  471.— Comminuted  stellate  fracture  of  patella  through  direct  violence  (X-ray  tracing). 


forty-five  years,  one  was  forty-seven  years  old  ;  practically,  a 
young  adult  scries.  Of  this  series  of  forty-seven  cases  ten  were 
treated  by  operation  and  the  remainder  by  the  expectant  method. 
These  cases  arc  not  mentioned  in  this  connection  to  compare 
methods  of  treatment,  but  to  determine  the  condition  of  the  knee 
a  long  time  after  the  injury.  As  a  matter  of  fact,  there  appeared 
no  greater  freedom  from  the  symptoms  complained  of  among  the 
cases  operated  on  than  among  those  unoperated.  The  results,  as 
(  , m  fully  recorded  in  these  forty-seven  eases,  suggest  some  of  the 
difficulties  that   patients  experience  after  fracture  of  the  patella. 


OPERATIVE    TREATMENT 


337 


The  detailed  reports  of  these  cases,  from  one  and  one-half  to  ten 
and  one-half  years  after  treatment  ceased,  show  that  about  twenty 
have  as  good  a  leg  as  before  the  accident.  The  remaining  twenty- 
seven  cases  complain  of  limitation  of  motion  at  the  knee-joint, 
that  the  knee  creaks  in  walking,  that  it  feels  stiff,  aches,  and  burns 
at  times.  The  leg  is  said  to  be  weak,  and  is  troublesome  in  going 
up  and  down  stairs — stepping  up  is  especially  difficult ;  kneeling 
is  painful  ;  stepping  upon   irregular  surfaces  is  painful ;   running 


Fig.  472. — Old  fracture  of  patella.  Much 
separation  of  fragments.  Small  nodules  of 
bone  seen  in  the  band  of  union  (X-ray  tracing). 


Fig.  473.— Old  fracture  of  patella. 
Wide  separation  of  fragments.  Dimp- 
ling of  skin.  A  useful  but  not  a  strong 
leg  (Massachusetts  General  Hospital, 
847.     X-ray  tracing). 


with  the  same  freedom  as  before  the  accident  is  impossible  ;  the 
knee  often  gives  way  in  walking  and  causes  a  fall  ;  the  patient 
can  not  jump  as  before  the  accident,  and  walks  with  a  slight  limp. 
Pain  is  present  in  or  about  the  knee  in  damp  weather  and  after 
unusual  exertion. 

Operative  Interference  in  Recent  Closed  Fractures  of  the 
Patella. — In  deciding  whether  a  given  case  should  be  treated 
by  operation  or  not  the  following  considerations  should  be  care- 


333 


FRACTURES    OF    THE    PATELLA 


fully  weighed  :  A  closed  fracture  of  the  patella  does  not  in  itself 
endanger  life.  It  may  be  treated  by  the  conservative  method 
without  added  risk.     If  properly  treated,  the  result  will  ordinarily 


Quadriceps  tendon. 


Upper  fragment  of  patella. 
Periosteum. 

Interposing  tissues. 

Lower  fragment  of  patella. 


Patellar  tend 


Joint  surface. 


—  Cartilage. 


Fig.  474. — Median  section  of  patella  and   tendons  (diagrammatic),  showing  interposition  ot 
fascia  and  periosteal  shreds  between  the  fragments. 


Fig. 475. — Fracture  of  patella ;  fragment  approximated  and  sutured  with  silver  wire.    Wire 
seen  m  .\itu  (X-ray  tracing.     C.  B.  Portei  I. 


be  satisfactory  as  far  as  the  functional  usefulness  of  the  knee  is 
concerned.  The  operative  method  consumes  less  time  in  conval- 
escence and  an  excellent  result  is  achieved,  but  operation  exposes 


OPERATIVE    TREATMENT 


339 


to  the  danger  of  sepsis.  If  sepsis  results,  the  following  conditions 
are  imminent :  A  stiff  knee,  amputation  of  the  thigh,  and  possibly 
death  from  septic  infection.  Whether  operation  shall  be  done  or 
not,  therefore,  depends  upon  the  degree  of  safety  with  which  it  can 
be  performed.  It  is  the  surest  method  of  securing  perfect  apposi- 
tion and  bony  union.  It  should  be  undertaken  only  by  surgeons 
of  exceptional  judgment  and  great  skill,  who  have  at  command 
skilled  assistants,  and  who  can  work  under  the  most  rigid  aseptic 
conditions.     The  acute  symptoms  should  be  allowed  to  subside 


Fig.  476. — Case:    Freshly   fractured   right  patella  sutured  with  chromieized  catgut.     Result 
after  eight  weeks.     Note  flexion  of  leg  to  a  right  angle  ;  line  of  incision  (Warren). 


before  operation.  The  tissues  require  time  to  recover  them- 
selves from  the  acute  trauma.  The  operative  treatment  should 
be  confined  to  healthy  individuals  under  sixty  years  of  age  ;  to 
fractures  with  a  separation  of  an  inch  or  more  of  the  bony  frag- 
ments and  extensive  lateral  fascial  tears  (the  fascial  tears  may  be 
recognized  by  joint  distention  and  localized  bulging)  ;  to  cases 
presenting  great  joint  distention  that  does  not  disappear  quickly. 
It  should  be  seriously  considered  if  the  individual's  occupation 
is  arduous  and  necessitates  much  standing  or  walking.  The 
patient  should  be  informed  as  to  the  probable  outcome  by  the 


34-0  FRACTURES    OF    THE    PATELLA 

two  methods  of  treatment.  The  danger  to  life  and  limb  should 
be  fairly  stated.  It  should  be  remembered  that  the  power  of 
extension  of  the  leg  is  not  materially  limited  by  a  transverse 
fracture  of  the  patella  in  which  the  tearing  of  the  lateral  fascia 
is  absent.  Only  in  direct  proportion  to  the  extent  of  the  lateral 
fascial  tear  is  there  limitation  of  the  power  of  extending  the  leg 
upon  the  thigh.  In  open  fractures,  in  refracture,  and  in  cases 
of  impaired  function  from  long  fibrous  union  or  from  adhesions 
of  the  patella  or  from  badly  united  patellae  mechanically  imped- 
ing the  movements  of  the  joint,  operation  is  always  indicated. 
The  working-man  who  wants  to  get  to  work  should,  under  the 
conditions  previously  stated,  have  his  patella  sutured,  for  he  will 
go  to  work  quicker  and  have  a  better  knee-joint  than  by  any 
method  of  treatment. 

Method  of  Operation. — The  joint  and  the  fractured  bones  are 
to  be  thoroughly  exposed  by  a  transverse  or  longitudinal  in- 
cision. All  clots  should  be  thoroughly  washed  or  sponged  out. 
Any  loose  small  fragments  of  bone  should  be  removed.  In 
almost  all  cases  a  rather  dense  fascia  will  be  found  overlapping 
the  broken  surfaces  of  the  two  fragments  (especially  is  this  seen 
in  a  transverse  fracture).  These  bits  of  overlapping  tissue  or 
curtains  of  tissue  should  be  retracted  and  removed  or  utilized  in 
suturing  the  fragments  (see  Fig.  474).  Whether  silver  wire  is 
employed  to  suture  the  bone  directly  or  whether  an  absorbable 
material  is  used  to  suture  the  soft  parts  seems  of  little  conse- 
quence as  long  as  all  fascial  tears  are  sutured  and  the  bony  frag- 
ments are  approximated  (see  Fig.  475).  The  weight  of  opinion 
to-day  is  in  favor  of  absorbable  sutures.  Closure  of  the  joint 
without  drainage  and  immobilization  in  the  extended  position 
followed  by  the  treatment  already  mentioned  are  indicated  (see 

Fig.  476). 

The  Restoration  of  the  Function  of  the  Joint  Following  the 
Operative  Treatment. — After  suture  of  the  patella,  massage  and 
gentle  passive  motion  should  be  begun  at  the  end  of  two  weeks. 
At  the  end  of  three  weeks  the  patient  may  go  about  with  the 
knee  protected  by  a  light  stiff  dressing.  After  about  six  weeks 
to  two  months  a  flannel  bandage  and  a  cane  will  be  all  the  pro- 
tection needed  to  the  knee.  At  the  end  of  three  months  the 
knee  should  be  functionally  perfect. 


CHAPTER  XIV 
FRACTURES    OF  THE   LEG 

Anatomy. — The  following  structures  may  be  palpated  :  The 
internal  and  external  tuberosities  of  the  tibia,  the  whole  of  the 
external    tuberosity    being    subcutaneous  ;    the    broad    anterior 


Fig.  477.— Middle  of  the  patella,  tubercle  of  the  tibia,  and  midpoint  between  the  malleoli  all 
lie  in  the  same  straight  line  as  the  leg  rests  naturally. 

and  inner  surface  of  the  tibia,  which  forms  the  shin,  downward 
to  the  internal  malleolus  ;  the  sharp  crest  of  the  tibia  through- 
out  its   whole  length  ;    the   head  of  the   fibula,   an   inch  below 

34i 


342 


FRACTURES    OF    THE    LEG 


the  top  of  the  tibia  ;  a  little  of  the  shaft  of  the  fibula  below 
the  head  and  the  attachment  of  the  biceps  tendon  ;  the  lower 
third  of  the  fibula  which  is  subcutaneous.  The  tubercle  of  the 
tibia  is  distinctly  felt  on  the  anterior  surface  of  the  upper  end  of 


/   i^Sv 


Fig.  478. — Fracture  of  the  tibia  ;  union 
with  displacement  forward  and  outward 
(Warren  Museum,  specimen  1140). 


Fig.  479.— Fracture  of  the  tibia  low 
down;  marked  outward  bowing;  union 
(Warren  Museum,  specimen  1146). 


the  tibia.  It  is  one  inch  from  the  articular  surface,  and  marks 
the  lowest  limit  of  the  upper  epiphysis  of  the  tibia.  Into  it  is 
inserted  the  patellar  tendon.  The  shaft  of  the  tibia  arches 
slightly  forward.  The  shaft  of  the  fibula  arches  slightly  back- 
ward.     The    broad    inner    malleolus    is    higher    than    the    outer 


ANATOMY"    OF    THE    TIBIA    AND    FIBULA 


343 


malleolus,  and  more  to  the  front  of  the  leg.  The  outer  malle- 
olus is  narrow.  The  posterior  edges  of  the  two  malleoli  are  in 
about  the  same  plane.      The  anterior  edge  of  the  external  malle- 


Fig.  480.— Fracture  of  the  left  fibula 
near  the  lower  end  ;  united.  View  from 
outer  side  (Warren  Museum,  specimen 
1150). 


Fig.  481. — Fracture  of  the  tip  of  the 
lower  end  of  the  left  fibula  ;  united.  View 
from  inner  side  (Warren  Museum,  speci- 
men 1151). 


Fig.  482. — Fracture  of  the  tibia  low  down  ;  displacement  of  the  upper  fragment  backward  ; 
union  (Warren  Museum,  specimen  7723). 


olus  is  about  an  inch  behind  the  anterior  edge  of  the  internal 
malleolus.  The  narrowest  part  and  the  weakest  place  in  the 
tibia  is  at  the  junction  of  the  lower  and  middle  thirds  of  the 
bone.      In  the  normal  leg  the  middle  of  the  patella,  the  tendon 


344 


ANATOMY    OF    THE    TIBIA    AND    FIBULA 


34! 


of  the   patella,  and  the   midpoint  of  the   ankle   are  in   the  same 
straight  line  (see  Fig,  477). 

General  Observations. — Fractures  of  the  tibia  and  fibula  may 
occur  at  any  point,  depending  upon  the  seat  and  direction  of  the 
fracturing  force.  If  the  force  is  indirect,  the  fracture  of  the  two 
bones  will  be  at  different  levels.      If  the  fracture  is  high  up,  the 


Fig.  484.— Fracture  of  both  bones  of  the 
leg;  union  with  considerable  displacement; 
cross  union  of  the  two  bones  ( Warren 
Museum,  specimen  5265). 


Fig.  485. — Fracture  of  both  bones  ot 
the  leg;  displacement  of  upper  fragments 
downward  and  inward  ;  union  (Warren 
Museum,  specimen  S303). 


knee-joint  may  be  involved  or  the  popliteal  vessels  and  peroneal 
nerve  may  be  implicated.  If  the  fracture  is  low  down,  the  ankle- 
joint  may  be  involved.  The  high  fracture  of  the  tibia  is  usually 
transverse.  The  low  fracture  of  the  tibia  is  usually  oblique.  The 
common  seat  of  fracture  is  at  about  the  junction  of  the  middle 
and   lower   thirds   of   the   lee.      The   line   of  the  fracture   is  an 


346 


FRACTURES    OF    THE    LEG 


oblique  one,  extending  from  above  and  behind  downward  and 
forward  through  the  tibia.  The  fibula  is  fractured  a  little  higher 
than  the  tibia.  If  the  force  is  considerable  and  the  sharpness  ot 
the  fragments  great,  the  overlying  skin  may  be  lacerated,  an 
open  or  infected  fracture  resulting.  The  upper  and  lower  epiph- 
yses of  the  tibia  may  be  separated  ;  these  are,  however,  rare 
injuries.  The  tibia  and  fibula  may  be  fractured  separately.  In 
such  cases  the  unbroken  bone  serves  as  a  splint  for  the  fractured 
one.      The  displacement  in  these  latter  fractures  is  slight. 


Fig.  486.— Method  of  measuring  the  length  of  the  tibia  from  the  internal  tuberosity  to  the 

internal  malleolus. 


Examination  of  a  Fractured  Leg. — It  is  sometimes  ex- 
tremely difficult  to  detect  a  fracture  of  the  leg.  It  is,  therefore, 
important  that  a  systematic  examination  should  be  made  imme- 
diately after  the  injury.  Deformity  will  ordinarily  be  apparent 
upon  inspection  (see  Fig.  488).  Gentle  manipulation  will  suffice 
to  satisfy  one  of  the  existence  of  a  fracture,  particularly  if  both 
bones  are  broken.  An  open  fracture  will  be  evident  if  a  wound 
exists  in  the  skin  near  the  seat  of  fracture.  In  taking  hold  ot 
the  leg  for  examination  or  for  moving  the  leg  it  should  not  be 
grasped  lightly  by  a  few  fingers  but  by  the  whole  hand  firmly, 
as    one    grasps    an    ax    handle    in    chopping   wood  ;  not  as  one 


MFTHOI)    OF    KX  AM  I  NATION 


347 


lifts  a  lead-pencil  from  the  table.  The  leg  should  be  so  raised 
in  making  the  examination  that  there  is  absolutely  no  risk  of  con- 
verting the  closed  fracture  into  an  open  one.  In  order  to  guard 
against  this  the  assistant  should  grasp  the  foot  at  the  ankle  and 
make  gentle  but  strong  traction  in  the  long  axis  of  the  leg  as  the 
whole  leg  is  raised.  This  care  in  examination  will  cause  the  patient 
a  minimum  amount  of  pain.      Crepitus  is  not  the  only  thing  that 


Fig.  487. — Fracture  of  both  bones  of  the  left  leg.     Comparative  height  of  knees  to  show 
shortening  of  leg  (after  Van  Leimep). 


is  to  be  sought  at  the  examination.  The  freedom  of  any  ab- 
normal mobility  should  be  noticed,  as  well  as  the  direction  of  the 
motion,  the  ease  with  which  reduction  is  possible,  and  the  liability 
to  recurrence  of  the  deformity.  If  there  is  any  doubt  as  to  the 
seat  or  extent  of  the  fracture,  the  examination  should  be  made  with 
the  assistance  of  an  anesthetic.  The  temporary  dressing  may 
be  applied  at  this  time.      The  bones  should  be  palpated.      While 


34§ 


FRACTURES    OF    THE    LEG 


an  assistant  steadies  the  knee-joint  the  surgeon,  grasping  the 
lower  part  of  the  leg,  attempts  motion  in  each  direction.  Simply 
raising  the  leg  and  attempting  motion  in  an  anteroposterior  direc- 
tion is  not  sufficient ;  a  fracture  of  the  tibia,  if  transverse,  might 
remain  completely  locked  except  upon  lateral  movement.  The 
tibia  should  be  measured  (see  Fig.  486)  from  the  knee-joint  line, 
at  the  upper  border  of  the  internal  tuberosity,  to  the  lower  edge 
of  the  internal  malleolus  to  determine  shortening.  Shortening 
of  the  leg  may  be  roughly  estimated  after  union  of  the  bones  by 
comparing  the  height  of  the  two  knees  while  the  soles  of  the  feet 
rest  upon  the  floor  (see  Fig.  487).  The  measurement  should 
be  compared  with  that  of  the  uninjured  tibia.  It  is  often  difficult 
in  fractures  near  the  ankle  to  palpate  the  internal  malleolus,  on 


Fig.  488.— Case  :  Fresh  fracture  of  the  leg  (hoth  bones).  Characteristic  deformity.  Note 
normal  position  of  patella,  with  the  foot  lying  on  its  outer  side.  Prominence  of  upper  frag- 
ment. Compare  this  with  figure  379  of  a  fracture  of  the  thigh  in  which  the  patella  does  not 
look  upward. 

account  of  swelling.  Deep  pressure  with  the  thumb  will  detect 
it.  Inquiry  should  be  made  as  to  whether  either  tibia  has  ever 
been  fractured  previously.  The  pulse  should  be  felt  for  in  the 
posterior  tibial  and  dorsalis  pedis  arteries  to  be  sure  that  the  large 
vessels  of  the  leg  are  intact. 

Symptoms. — Ordinarily,  the  presence  of  pain,  deformity, 
abnormal  mobility,  crepitus,  and  loss  of  use  of  the  leg  will  be 
the  evidences  of  fracture.  If  the  fracture  is  of  the  tibia  or  fibula 
alone  and  transverse  without  much  displacement,  localized  ten- 
derness upon  pressure  and  swelling  will  be  the  only  signs.  It  is 
important  to  remember  the  backward  bowing  of  the  fibula  in  at- 
tempting to  localize  by  palpation  the  tender  point  of  the  fracture 
of  that  bone. 


SYMPTOMS 


349 


The  deformity  is  due  to  the  displacement  of  the   upper  frag- 
ment forward  and  of  the  lower  fragment  upward  and  backward. 


Fig.  489.— 


Fracture  of  the  tihia,  oblique  and  high  up.  Almost  no  displacement  (Massachusetts 
General  Hospital,  1235.     X-ray  tracing). 


Tibia. 


Fibula. 


Fig.  490. — Fracture  of  the  external  tuberosity  of  the  tibia  (Massachusetts  General  Hospital, 

1242.    X-ray  tracing). 


If  the  fracture  is  oblique,  this  displacement  will  be  considerable. 
The  lower  fragment  is  often  rotated  upon  its  longitudinal  axis, 
so  that  the  foot  rests   upon   its  side,  while  the   upper  fragment 


35o 


FRACTURES    OF    THE    LEG 


remains    undisturbed  by  rotation,    the   patella   looking   directly 
upward  (see  Fig.  488). 

The  swelling  will  vary.  It  may  be  extremely  slight  and 
limited  to  the  seat  of  the  fracture  or  it  may  extend  over  the 
entire  leg.  The  maximum  swelling  of  the  leg  is  usually  reached 
three  or  four  days  after  the  accident.  If  the  fracture  was  caused 
by  direct  violence  and  the  fragments  of  bone  are  sharp,  the  soft 
parts  will  be  damaged  and  the  resulting  hemorrhage  and  swell- 
ing will  be  very  considerable. 


Fig.  491.  —  Longitudinal  Assuring  of 
tibia  from  blasting  accident.  Front  view 
(X-ray  tracing). 


Fig.  492.  —  Longitudinal  Assuring  ol 
tibia  from  blasting  accident.  Lateral  view. 
Same  as  figure  491  (X-ray  tracing). 


Ecchymosis  of  the  skin  appears  in  from  twenty-four  to  forty- 
eight  hours  after  the  accident  ;  it  may  extend  over  the  whole  leg. 
Ecchymosis  from  a  sprain  is  localized  more  or  less  about  the  seat 
of  the  sprain  ;  that  from  a  fracture  is  often  extensive.  Blebs  or 
vesicles  may  appear  near  the  fracture  during  the  first  week  if  the 
swelling  is  great.  It  is  necessary  to  exercise  great  caution  in  the 
care  of  these  blebs,  that  they  do  not  become  infected. 

Fracture  of  the  shaft  of  the  fibula  may  be  very  obscure,  but 
pressure    upon   the   fibula   toward   the    tibia   will    elicit   pain   and 


TREATMENT  35 1 

crepitus.  In  separation  of  the  lower  epiphysis  of  the  tibia  the 
preservation  of  the  normal  relations  between  the  malleoli  is  of 
considerable  diagnostic  importance. 

Treatment. — For  purposes  of  treatment  fractures  of  the  leg 
are  arranged  into  several  distinct  groups — viz.: 

1.  Fractures  with  little  or  no  swelling  or  displacement. 

2.  Fractures  with  considerable  swelling. 


Fig-.  493. — Oblique  fracture  of  the  tibia 
low  down,  and  oblique  fracture  of  the  fibula 
at  its  middle  (X-ray  tracing). 


Fig.  494. —  Fracture  of  both  bones  ot 
the  leg  at  the  middle ;  slightly  spiral  of  tibia 
(Massachusetts  General  Hospital,  1134. 
X-ray  tracing). 


3.  Fractures  with  a  displacement  of  fragments  difficult  to  hold 
corrected. 

4.  Open  fractures. 

The  indications  to  be  met  by  treatment  in  each  of  these  groups 
are  correction  of  deformity,  immobilization  of  fragments,  and  res- 
toration of  the  limb  to  its  normal  condition. 

Fractures  with  Little  or  No  Displacement  or  Swelling. — 
Fractures  of  the  tibia  alone   or   the   fibula  alone  are   properly 


352 


FRACTURES    OF    THE    LEG 


placed  in  this  group.  Fractures  of  both  bones  occasionally 
occur  with  little  or  no  displacement  and  with  but  a  trifling 
amount  of  swelling.  In  these  cases  the  leg  should  be  elevated 
for  ten  minutes  in  order  to  lessen  the  swelling.  The  foot,  leg, 
and  lower  thigh  are  then  bathed  with  soap  and  water,  and 
thoroughly  dried  and  powdered.      The  leg  being  properly  pro- 


p's- 495- — Oblique  fracture  of  both 
bones  of  the  leg.  Displacement  of  the 
upper  fragments  in  the  same  inward  direc- 
tion 1  Massachusetts  General  Hospital,  749. 
X-ray  tracing). 


Fig.  496. — Transverse  fracture  of  both 
bones  of  the  leg  at  the  middle;  slight 
displacement  and  considerable  bowing 
(Massachusetts  General  Hospital,  1215. 
X-ray  tracing). 


tected,  a  light  plaster-of-Paris  roller  bandage  is  applied  from 
the  toes  to  the  middle  of  the  thigh.  (See  Details  of  Plaster 
Work.)  The  leg  is  to  be  kept  elevated  for  the  first  week  by 
at  least  two  or  three  pillows.  If  good  judgment  is  exercised 
in  the  subsequent  care  of  the  case,  the  placing  of  such  a  frac- 
ture, as  previously  indicated,  immediately  in  a  plaster-of-Paris 
splint   is  attended  by  no  risk.      The  danger    lies  in   too  great 


TREATMENT 


353 


pressure  upon  the  circulation,  caused  by  the  increasing  swelling 
of  the  leg  within  the  unyielding  plaster  splint.  Pressure  sores 
and  gangrene  are  liable  to  result.  In  applying  the  splint  a 
liberal  amount  of  sheet  wadding  should  be  used.  The  condition 
of  the  circulation  should  be  noted  immediately  after  the  application 
of  the  splint  and  at  regular  intervals  thereafter  until  all  danger 
from  undue  pressure  has  ceased.  Evidences  of  too  great  pressure 
are  persistent  or  increasing  swelling  of  the  toes,  blueness  of  the 
toes,  and  pain.  It  is  well,  in  order  to  avoid  undue  pressure  upon 
the  leg,  to  split  the  plaster  the  entire  length  of  the  splint  before 


Fig:.  497- — Double  fracture  of  the  tibia. 
Single  fracture  of  the  fibula  (Massachusetts 
General  Hospital,  1055.     X-ray  tracing). 


Fig.  498. — Fracture  of  the  fibula  without 
injury  to  the  tibia  (Massachusetts  General 
Hospital,  1230.     X-ray  tracing). 


it  has  quite  hardened.  The  splint  loses  by  this  procedure  none 
of  its  immobilizing  qualities,  for  it  can  be  bandaged  or  strapped 
tightly  together  again.  Too  great  pressure  upon  the  circulation 
can  then  be  immediately  relieved  by  loosening  the  retaining  straps 
or  bandage  and  thus  opening  the  splint.  After  the  splint  has  been 
on  the  leg  for  about  a  week  and  a  half  or  two  weeks,  the  swell- 
ing having  begun  to  subside,  the  plaster  splint  will  become  loose 
and  will  cease  to  hold  the  fragments  firmly.  Unless  a  new  and 
snug  splint  is  now  applied,  it  will  be  necessary  to  cut  out  a 
strip  of  plaster  an  inch  or  more  wide  from  the  old  splint  to  admit 


354 


FRACTURES    OF    THE    LEG 


of  tightening.  During  the  changing  of  the  plaster  splint  the  leg 
should  be  steadied  by  an  assistant  while  it  is  thoroughly  washed 
with  soap  and  water  and  bathed  with  alcohol. 

Fractures  with  Considerable  Immediate  Swelling. —  Many 
fractures  are  not  seen  by  the  surgeon  until  two  or  three  hours 
after  they  have  occurred,  when  considerable  swelling  is  present. 
Associated  with  such  primary  swelling  there  will  be  laceration 
of  the  soft  parts  and  possible  extensive  injury  to  the  bone. 
Blebs  filled  with  clear  or  bloody  serum  may  be  present  about  the 


Fig.  499. — Fracture  of  the  fibula  low 
down  without  fracture  of  the  tibia  (X-ray 
tracing). 


Fig.  500. — Oblique  fracture  of  both 
bones  of  the  leg  low  down.  Fracture 
difficult  to  hold  in  good  position  (Massa- 
chusetts General  Hospital,  1024.  X-ray 
tracing). 


seat  of  fracture.  These  should  be  evacuated  after  the  part  has 
been  rendered  surgically  clean  by  washing  with  soap  and  water 
and  corrosive  sublimate  solution,  and  then  dressed  with  a  dry 
antiseptic  powder,  powdered  dermatol.or  aristol.  Infection  may 
take  place  through  blebs.  Very  great  care  should  be  exercised 
in  their  treatment.  Obviously,  it  is  unwise  immediately  to  apply 
a  plaster-of- Paris  splint  to  cases  in  which  there  are  many  blebs 
and  much  swelling.  The  swelling  of  the  leg  may  become  so  great 
that  the  life  of  the  limb  may  be  at  stake,  the  danger  from  im- 
pending gangrene   becoming  imminent.      In  such  cases  the  skin 


TREATMENT  35  5 

of  the  leg  becomes  tense  and  shiny,  the  leg  feels  hard  and  board- 
like, pain  may  be  extreme,  and  the  toes  and  foot  become  slightly 
blue.  The  hemorrhage,  being  confined  beneath  the  fascia  and 
skin,  causes  pressure  upon  the  circulation.  The  circulation  in 
the  leg  is  thus  impeded.  Under  such  circumstances  operation  is 
necessary  in  order  to  relieve  tension  and  to  check  hemorrhage. 


Fig.  501. — Fracture  of  both  bones  of 
the  leg  from  bullet-wound.  Characteristic 
comminution  of  the  bones.  Bullet  not  re- 
moved. Recovery  with  a  useful  leg  (X-ray 
tracing)   (Warren). 


\ 


Fig.  502. — Transverse  fracture  of  the 
tibia,  high.  Direct  violence.  Great  swell- 
ing of  leg.  Threatening  gangrene.  Free 
incisions.  Leg  saved.  Result  good.  Same 
case  as  figure  503  (Massachusetts  General 
Hospital,  1064.     X-ray  tracing)   (Scudder). 


Incisions  in  the  long  axis  of  the  limb  through  skin  and  fascia 
will  be  followed  by  a  rapid  decrease  in  the  swelling  of  the 
leg  and  a  cessation  of  the  pain.  After  incision,  the  bleeding 
vessels  found  should  be  ligated.  The  bones  may  be  sutured  at 
this  time  if  it  is  thought  wise.  If  these  wounds  remain  aseptic, 
they  may  be  closed  after  a  few  days  by  suture  or  may  be  allowed 


356 


FRACTURES    OF    THE    LEG 


to  heal  openly.  This  method  of  treatment  will  usually  result  in 
saving  the  leg  (see  Figs.  502,  503).  If  the  circulation  does  not 
return  and  gangrene  is  imminent,  immediate  amputation  of  the 
limb  well  above  the  fracture  at  the  lower  or  middle  third  of  the 


Fig.  503. — Case:  Closed  fracture  of  the  left  tibia.  Hematoma.  Impairment  of  the  circu- 
lation. Free  incisions.  Evacuation  of  blood.  Relief  of  pressure.  Leg  saved.  Recovery 
(Scudder). 


A 

w4* 

!~ 

___ 

|          ^ 

Fig.  504.  —  Fracture  of  the  leg.     Temporary  or  emergency  dressing.     Application  of  the  pillow 
with  straps.     Open  end  of  the  pillow-case  at  the  foot. 


thigh  is  the  only  procedure.  Traumatic  gangrene  is  often  rapidly 
followed  by  general  septic  infection.  It  is  best  to  use  a  tem- 
porary dressing  in  cases  in  which  there  is  great  initial  swelling 
of  the  le<r. 


TREATMENT 


357 


The  Temporary  Dressing. — The  Pillow  and  Side  Splints. — 
The  leg  is  placed  on  a  pillow  covered  with  a  pillow-case  ;  straps 
are  placed  under  the  pillow  and  drawn  snugly  up  about 
the  leg  (see  Fig.  504).  The  edges  of  the  pillow  are  rolled  in 
against  the  leg  for  firmness.  Narrowly  folded  towels  are  placed 
between  the  leg  and  the  straps.  The  straps  are  then  drawn 
tighter.     The  open  end  of  the  pillow-case  is  folded  and  pinned 


Fig.  505. — Fracture  of  the  leg.    Pillow  and  side  splints  with  straps  and  towels.     Compare 

figure  506. 


Fig.  506. — Fracture  of  the  leg.     Temporary  or  emergency  dressing.     Pillow,  side  splints,  and 
straps.     Pillow  held  by  shield-pins. 


under  the  sole  of  the  foot.  Three  pieces  of  splint  wood  are 
introduced  between  the  pillow  and  straps — one  is  slipped  under- 
neath and  one  upon  each  side  of  the  pillow.  The  pillow 
thus  serves  as  a  padding  for  the  box  formed  by  the  splint  wood 
(see  Fig.  505).  Ice-bags  may  be  conveniently  placed  along  the 
anterior  surface  of  the  leg  between  the  edges  of  the  pillow.  They 
relieve  pain  and  are  said  to  check  hemorrhage  immediately  after 


358 


FRACTURES    OF    THE    LEG 


the  fracture.  If  greater  security  is  thought  necessary,  the  pillow- 
case, instead  of  having  its  sides  rolled  in,  may  be  pinned  with 
shield-pins  up  over  the  anterior  surface  of  the  leg  (see  Fig.  506). 


Fie.  soy.-Diagram  of  oblique  fracture  of  the  leg.    Displacement  upward  and  forward  of  the 


ower  fragment. 


Fig   soS  -Diagram  illustrating  a  frequent  method  of  apparently  correcting  the  displacement, 
6'  D  which  results  in  producing  a  backward  bowing. 


Fie  Soo.-Diagram  illustrating  the  proper  direction  in  which,  combined  with  traction,  force 
should  be  exerted  in  order  to  correct  the  displacement. 

This  temporary  dressing  is  left  in  place  for  a  week  or  a  week  and 
a  half.  The  swelling  will  then  have  partly  subsided.  If  at  this 
time  there  is  little  or  no  swelling  and  the  displacement  is  slight, 


TRKATMKXT 


359 


a  plaster-of-Paris  splint  may  be  applied  as  a  permanent  dressing  ; 
it  is  split  or  not  as  circumstances  indicate.  If,  on  the  other 
hand,  at  the  end  of  a  week  or  a  week  and  a  half  it  is  desired  to 
have  the  fracture  open  to  inspection  and  more  directly  accessible 
and  under  the  eye  of  the  surgeon,  then  the  posterior  wire  and 
side  splints  should  be  applied. 

The  Permanent  Dressing  for  Fracture  of  the  Leg. — Several 
important  things  are  to  be  kept  constantly  in  mind  in  placing  a 
fractured  leg  in  a  permanent  splint.  They  are  as  follows  :  The 
alinement  of  the  bones  of  the  leg  is  to  be  maintained  ;  rotation 
of  either  fragment  upon  its  long  axis  is  to  be  avoided  ;  the  foot 
is  to  be  kept  extended  to  a  right  angle  with  the  leg  ;  lateral  devi- 
ation is  to  be  avoided  ;  the  inner  side  of  the  great  toe,  the  middle 


Fig.  510. — Padding  the  Cabot  posterior  wire  splint.     Applying  sheet  wadding 
and  proportions  of  the  Cabot  splint  are  apparent. 


The  shape 


of  the  patella,  and  the  anterior  superior  spine  of  the  ilium  should 
be  in  one  straight  line  ;  anteroposterior  deformity  is  to  be  avoided 
(the  convexity  of  this  curve  of  deformity  is  usually  backward  ;  it 
is  a  hyperextension  of  the  leg  at  the  seat  of  fracture)  (see  Figs. 
507—509)  ;  frequent  measurements  and  inspection  of  the  leg 
should  be  made  ;  inspection  should  be  made  not  only  from  the 
front,  but  laterally  as  well ;  readjustment  of  apparatus  is  neces- 
sitated by  changes  in  the  position  of  the  bones. 

The  Posterior  Wire  and  Side  Splints. — The  posterior  wire  or 
Cabot  splint  is  made  of  iron  wire  the  size  round  of  an  ordinary 
lead-pencil  (see  Fig.  510).  It  is  applied  to  the  back  of  the  foot, 
leg,  and  thigh,  extending  from  just  beyond  the  tips  of  the  toes  to 


360  FRACTURES    OF    THE    LEG 

above  the  middle  of  the  thigh.  It  is  narrow  at  the  heel  and  broad 
enough  above  to  permit  the  thigh  to  rest  comfortably  upon  it. 
The  foot-piece  is  at  right  angles  to  the  leg. 

Having  at  hand  the   iron  wire  the   size  of  an   ordinary  lead- 
pencil,  this  splint  can  be  quickly  and  easily  made  by  means  of  a 


Fig.  511. — Padding  (he  Cabot  posterior  wire  splint:  (1)  With  sheet-wadding  (see  Fig. 
510)  ;  (2)  with  a  cotton  roller  around  the  wire,  and  (3)  around  both  wires,  to  form  a  back  to 
the  splint. 

vise  for  holding  the  wire,  and  a  wrench  for  grasping  the  wire 
while  bending  it.  The  two  free  ends  of  the  wire  of  the  splint 
may  be  held  firmly  together  by  having  them  overlap  and  bind- 
ing them  together  with  small-sized  copper-wire.  These  free 
ends  may,  of  course,  be  held  by  solder. 

The    Covering  of   the    Posterior   Wire   Splint. — The    wire    is 


THE    CAKE    OF    THE    HEEL  36 1 

wound  first  with  a  roller  of  sheet  wadding,  then  with  a  cotton 
roller,  and  finally  a  cotton  roller  bandage  is  wound  about  both 
sides  of  the  splint  so  as  to  make  a  posterior  surface  upon  which 
the*  leg  may  rest  (see  Figs.  510,  511,  512). 

The  side  splints  of  wood  (see  Fig.  513)  should  be  about  four 
inches  wide,  and  long  enough  to  extend  from  the  foot-piece  to 
the  top  of  the  splint.  The  side  splints  may  be  covered  with 
sheet  wadding  and  cotton  cloth,  as  seen  in  the  figure. 

Care  of  the  Heel. — If  but  slight  pressure  is  maintained  upon 
the  heel  even  for  a  few  days,  a  pressure  sore  will  develop.  This 
is  liable  to  increase  to  a  considerable  size.  It  is  very  slow  in 
healing.  Many  weeks  after  the  fracture  of  the  leg  has  united 
the  pressure  sore  may  be  open.      It  is,  therefore,  of  very  great 


Fig.  512. — The  Cabot  posterior  wire  splint  padded  completely.     Note  the  foot-pad  of  paste- 
board covered  by  cotton-cloth  pinned  to  the  foot-piece  of  the  splint  for  greater  securit}-. 


importance  to  prevent  pressure  upon  the  heel  during  the  treat- 
ment of  fractures  of  the  lower  extremity  associated  with  dorsal 
decubitus.  There  are  four  methods  of  avoiding  pressure  on  the 
heel.  Position  will  assist  materially.  The  position  of  the  foot 
largely  determines  the  amount  of  pressure  falling  on  the  heel. 
When  the  foot  rests  naturally,  it  is  in  the  position  of  slight 
plantar  flexion.  The  heel  presses  firmly  upon  the  splint  (see 
Fig.  514).  A  large  part  of  the  weight  of  the  leg  thus  falls  upon 
the  heel.  When  the  foot  is  extended  to  a  right  angle  with  the 
leg,  the  pressure  upon  the  heel  is,  in  a  large  measure,  removed 
(see  Fig.  515).  Therefore,  in  putting  up  fractures  of  the  leg  the 
right-angle  position  is  the  desirable  one.  Padding  above  the 
heel  is  of  service.      The  ring  or  doughnut  pad  around  the  heel 


362  FRACTURES    OF    THE    LEG 

is  sometimes  efficient.  Slinging  the  foot  by  adhesive  straps  ap- 
plied to  the  sides  of  the  heel  and  foot  and  fastened  to  the  foot- 
piece  of  the  splint  is  a  very  satisfactory  method  of  removing 
pressure  from  the  point  of  the  heel  (see  Fig.  516). 

The  Padding  of  the  Posterior  Wire  Splint  for  the   Reception 
of  the  Lower  Extremity. — Regard  should  be  had  for  the  natural 


Fig.  513. — Side  splint  oi  splint  wood  (3).    Method  of  padding:  (1)  With  sheet  wadding;  (2) 
with  cotton  cloth  ;  (4)  pinned  in  place,  and  then  (5)  stitched. 


curves  of  the  leg  and  thigh  posteriorly  (see  Fig.  515).  Above  the 
heel,  behind  the  knee,  and  below  the  buttock  arc  distinct  hollows, 
at  which  places  the  padding,  as  indicated  in  the  illustration, 
should  be  thicker  than  at  other  points.  Regard  should  likewise 
br  had  for  the  natural  lateral  curves  of  both  thigh  and  leg.  Just 
below  the  malleoli,  above  the  ankle,  below  the  knee,  and  above 


THE    PADDING    OF    THE    POSTERIOR    SPLINT 


363 


the  knee  are  distinct  hollows  that  will  require  more  padding  than 
elsewhere  on  the  sides  of  the  limb  (see  Fig.  517).  The  more 
carefully  the  splint  is  padded,  the  more  nearly  perfect  will  be 
the  result  of  treatment  and  the  greater  will  be  the  comfort  of  the 
patient. 

The  leg  is  to  be  placed  upon  the  posterior  wire  splint,  so 
padded  posteriorly  that  it  rests  naturally  and  comfortably.  The 
foot  should  be  placed  at  a  right  angle,  drawn  down  snugly  to  the 


pjg.  514.— Normal  leg  with  foot  flexed,  showing  that  the  heel  rests  heavily  on  the  table  (see 

Fig-  5'5)- 


P"'g-  5T5  —  Posterior  outline  of  the  normal  leg,  suggesting  the  necessary  padding  to  be 
used  on  the  Cabot  splint.  _When  the  foot  is  at  aright  angle  with  the  leg,  the  heel  rests  lightly 
on  the  table. 


foot-piece,  and  steadied  by  adhesive-plaster  straps  carried  around 
the  foot  and  splint  in  a  figure-of-eight  bandage  (see  Figs.  519, 
520).  The  side  splints,  so  padded  with  pillow-cases  or  towels  as 
to  bring  suitable  pressure  upon  the  leg  and  thigh,  are  applied  and 
held  in  position  by  straps  and  buckles  (see  Fig.  520).  This  splint 
immobilizes  the  knee-  and  ankle-joints  and  the  fractured  bones. 
The  region  of  the  fracture  is  open  to  inspection  anteriorly. 
Lateral  inspection  is  facilitated  by  loosening  the  straps  and  lower- 


364 


FRACTURES    OF    THE    LEG 


ing  the  side  splints.  Any  deviation  from  the  normal  lines  of  the 
leg  can  be  adjusted  easily.  At  the  end  of  three  weeks,  when  the 
fracture  is  uniting  and  the  callus  is  still  soft,  the  leg  should  be 
removed  from  the  splint  and  examined  carefully  from  the  front, 
from  the  back,  and  laterally  for  any  deviation  from  the  normal. 
If  any  deviation  is  discovered,  it  should  be  corrected  and  the  leg 
put  again  into  a  posterior  wire  splint  or  into  a  removable  plaster- 
of-Paris  splint. 


Fig.  51b. — Methods  of  supporting  the  foot  in  fractures  of  the  leg  when  using:  a  posterior  splint. 
a,  Padding  beneath  tendo  Achillis  ;  b,  ring  under  heel ;  c,  sling  of  adhesive  plaster. 


The  first  night  after  putting  up  the  fracture  the  patient  will 
probably  be  most  uncomfortable.  The  new  and  restrained  posi- 
tion, the  after-effect  of  the  anesthetic  if  one  has  been  used,  the 
points  of  undue  pressure  yet  to  be  adjusted,  the  itching  of  the 
skin,  the  inability  to  move  about,  the  necessity  of  lying  in  one 
position,  actual  pain  at  the  seat  of  the  fracture — all  combine 
to  make  life  miserable.  It  will  be  a  wise  precaution  on  the 
part  of  the  attendant  if  a  little  morphin  is  administered  subcu- 
taneously  this  first  night,  as  patient,  nurse,  and  physician  will 


TREATMENT 


365 


rest  better.  After  the  first  night  there  will,  under  ordinary  cir- 
cumstances, be  no  especial  difficulty.  After  the  plaster  splint  is 
applied  the  Smith  anterior  wire  splint  attached  to  the  anterior 
surface  of  the  thigh,  leg,  and  dorsum  of  the  foot  often  will  enable 
the  leg  to  be  slung  just  so  as  to  clear  the  bed.  This  position  is 
one  of  considerable  comfort.      The  patient  is  enabled  to  move  in 


Fig.  517.— Fractures  of  the  leg.     Cabot  posterior  wire  splint  and  side  splints,  showing  the 
space  to  be  padded  on  each  side  of  the  leg  and  thigh. 


bed  a  little  and  to  change  his  position  without  disturbing  the 
fracture.  This  anterior  wire  splint  is  made,  like  the  Cabot  pos- 
terior wire  splint,  of  iron  wire,  but  is  fitted  to  the  anterior  surface 
of  the  foot,  leg,  and  thigh  (see  Fig.  518). 

Fractures  Difficult  to  Hold  Reduced. — These  are  usually  ob- 
lique fractures  of  the  tibia,  occurring  most  often  in   the  lower 


366 


FRACTURES    OF    THE    LEG 


half  of  the  bone.      The  nearer  to  the  ankle-joint  the  fracture  is, 
the  greater  is  the  likelihood  of  a  displacement  which  is  hard  to 


At  the  foot 


Suspension    At  the 
hooks.         pelvis. 


Fig.  518. — The  anterior  wire  suspensory  apparatus  of  N.  R.  Smith.  This  splint  is  applied 
to  the  anterior  surfaces  of  the  padded  foot,  leg,  thigh,  and  hip.  The  splint  is  fixed  to  the  leg 
by  a  bandage.  The  splint  is  intended  to  immobilize  the  leg  and  at  the  same  time  to  suspend 
it,  permitting  motion  at  the  hip,  and  to  secure  extension  upon  the  distal  fragments. 


!k 

»; 

Fig-  519- — Fracture  of  the  leg.     Cabot  posterior  wire  splint  padded  properly  according  to  the 
curves  of  the  normal  leg.     Note  that  the  heel  is  free  from  the  splmt  (see  Fig.  515). 


Fig.  520. — Fracture  of  the  leg.    Cabot  posterior  wire  splmt,  m<1c-  and  posterior  wooden  splint 
held  by  snaps.     Adhesive  plaster  to  foot  and  ankle. 


hold  reduced.  The  contraction  of  the  quadriceps  extensor  tends 
to  pull  the  upper  fragment  forward,  the  contraction  of  the  gas- 
trocnemius  tends   to    pull   the    lower    fragment    backward    and 


TKKATMENT 


3rV 


upward.  The  obliquity  of  the  fracture  and  the  action  of  these 
two  groups  of  powerful  muscles  make  it  almost  an  impossibility 
to  hold  these  fractures  reduced.  It  is  often,  even  under  an 
anesthetic,  impossible  to  correct  the  deformity  without  doing  a 


Fig.  521. — Short-Desault  splint  for 
the  application  of  traction  to  lower  leg 
fractures.  Fracture  at  X.  Extension 
strips  up  from  the  fracture  are  fastened 
at  the  top  of  the  splints.  Extension 
strips  down  from  the  fracture  are  fast- 
ened to  the  foot-piece.  Tightening  the 
screw  at  foot-piece  makes  traction  and 
countertraction. 


Fig.  522. — Plaster  traction  splint:  a.  Appli- 
cation of  adhesive-plaster  extension  strips  as 
in  figure  521  ;  d,  plaster  bandage  allowing  exit 
of  extension  straps.  Note  space  left  below  the 
sole  to  allow  for  effective  traction  and  buckles 
to  which  the  upper  extension  is  attached. 


tenotomy  of  the  tendo  Achillis.  A  posterior  wire  and  side  splints 
with  the  foot  held  fixed,  with  a  moderate  traction  and  pads  placed 
at  the  seat  of  fracture,  may  be  of  service. 

A  plaster-of-Paris  splint  with  extension  and  counterextension, 
after  the  principle  of  the  Short-Desault  apparatus  and  according 


368 


FRACTURES    OF    THE    LEG 


to  Lovett's  adaptation  (see  Figs.  521,  522),  will  hold  some  of  the 
more  difficult  cases. 

Method  of  Application  of  the  Traction  Plaster-of-Paris  Splint. — 
From  the  seat  of  fracture  running  upward  and  from  the  seat 
of  fracture  running  downward  are  applied  extension  adhesive 
plasters,  with  webbing  attachments,  as  seen  in  the  diagram  (see 
Fig.  522).  Below  the  foot,  the  size  of  the  sole  of  the  foot  and 
two  inches  thick,  is  held  a  very  firm  pad  of  sheet  wadding.  A 
plaster  bandage  is  applied  to  the  leg,  according  to  the  usual 
methods,  from  the  toes  to  above  the  knee.  A  buckle  looking 
upward  is  incorporated  in  the  plaster  bandage  upon  each  side 
of  the  lee  a  little  above  the  level  of  the  knee.      A  slit  is   left 


Fig.  523. — Cabot  posterior  wire  splint,  as  used  for  open  fractures  (lateral  view).  Note 
protective  padding  of  splint  beneath  wound,  X,  to  facilitate  dressings  without  the  removal  ot 
the  leg  from  the  splint. 


upon  each  side  of  the  ankle  for  the  lower  extension  webbings  to 
come  through  (see  Fig.  522).  After  the  plaster  has  hardened 
the  sheet-wadding  foot-pad  is  removed.  The  upper  extension 
straps  are  pulled  snugly  over  the  upper  edge  of  the  plaster 
splint  and  fastened  to  the  buckles  on  each  side.  Then  the  lower 
straps  are  pulled  taut  over  the  foot-piece  of  the  plaster.  Coun- 
tertraction  and  traction  are  thus  maintained  upon  the  fragments 
of  the  fracture.  A  window  is  cut  in  the  plaster  to  observe  the 
position  of  the  bones.  This  apparatus  is  efficient  in  many  in- 
stances in  which  it  is  otherwise  difficult  to  maintain  reduction. 

Operative  interference  with  suture  of  the  fragments  of  bone  is 
the  most  effective  method  of  treatment  in  troublesome  cases.  It 
is  always  wise   to  delay  operating  until  after  the  primary  effects 


TREATMENT    OF    OPEN    FRACTURES 


369 


of  the  injury  have  ceased — that  is,  until  after  the  acute  swelling 
has  subsided  and  the  damaged  tissues  have  had  time  to  recover 
themselves.  A  delay  often  days  is  time  gained.  During  these 
ten  days  some  one  of  the  methods  already  mentioned  may  suc- 
ceed in  holding  the  fracture  satisfactorily  so  that  operation  is 
unnecessary. 


Fig-  524. — Cabot  wire  splint  in  open  fractures,  viewed  from  above.  Leg  in  position  ; 
wound  of  soft  parts  seen  ;  dressing  removed;  side  splints  and  straps  seen.  Upper  and  lower 
fragments  held  by  permanent  bandages  during  inspection  of  the  wound. 


Treatment  of  Open  Fractures  of  the  Leg. — Treatment  rests 
upon  the  presumption  that  every  open  fracture  is  infected.  The 
object  of  treatment  is  to  convert  the  open  infected  fracture  into 
a  closed  noninfected  fracture.  It  is  important  that  the  first  dress- 
ing of  the  wound  should  be  a  clean  one.  If  it  is  a  temporary 
24 


37Q 


FRACTURES    OF    THE    LEG 


dressing,  the  wound  should  be  douched  with  boiled  water,  cov- 
ered with  a  clean  absorbent  dressing,  and  the  leg  be  placed  upon 
a  pillow  splint. 

The  Permanent  Dressing. — Every  open  fracture  of  the  leg 
should  be  anesthetized  for  careful  examination,  diagnosis,  and 
the  initial  dressing.  The  leg  should  be  washed  with  soap  and 
water  and  scrubbed  with  a  gauze  sponge  or  soft  nail-brush.  The 
leg  should  be  shaved  of  all  hair  in  the  vicinity  of  the  wound, 
and  should  then  be  washed  with   liquor  sodse  chlorinate  (chlor- 


Fig.  525.— Fracture  of  both  bones  of  the  leg.     Ununited  fracture  of  tibia.     Fibula  united 
(Massachusetts  General  Hospital,  nyo.    X-ray  tracing) . 


inated  soda),  one  part  to  twenty.     This  will  most  effectively  free 
it  from  all  grease  and  oily  dirt. 

The  Wound  of  the  Soft  Parts. — This  should  be  moderately 
enlarged  to  allow  easy  access  to  its  deeper  parts.  There  are, 
no  doubt,  cases  of  fracture  of  the  bones  of  the  leg  open  from 
within  outward  in  which  the  wound  is  small,  evidently  made  by 
the  bone,  in  which  it  is  prudent  to  seal  the  wound  and  to  regard 
the  likelihood  of  infection  as  absent.  These  cases,  chosen  in 
the  judgment  of  a  wise  surgeon,  may  do  well,  but  they  may  not ; 
therefore,  the  author  believes  it  is  safer  to  advise  that  all  wounds 


TREATMENT  OF  OPEN  FRACTURES  37 1 

of  open  fractures  be  enlarged  for  thorough  cleansing.  The  blood- 
clot  and  detritus  should  be  washed  out  by  irrigating  with  a  warm 
solution  of  corrosive  sublimate,  1  :  5000.  Irrigation  should  be 
supplemented  by  thorough  scrubbing  of  the  tissues  of  the  wound 
by  small  gauze  swabs  held  in  forceps.  These  swabs  should  be 
small  enough  to  be  carried  into  all  the  recesses  of  the  wound. 


Fig.  526. — Open  fracture  of  both  bones  of  the  right  leg  in  the  lower  third,  six  months  after  the 
accident.     Note  the  deformity  and  enlargement  of  the  leg  near  the  ankle. 

All  bleeding  should  be  checked.  Loose  bits  of  muscle,  fat, 
fascia,  and  bone  should  be  removed.  Often  the  finger  will 
detect  bits  of  bone  when  the  forceps  will  not.  The  firmly 
attached  fragments  of  bone  are  to  be  left  undisturbed.  Regard- 
ing the  treatment  of  the  slightly  fixed  fragments  of  bone,  the 
surgeon  must  judge  in  each  instance.     It  is  a  good  rule  when  in 


372 


FRACTURES    OF    THE    LEG 


doubt  about  the  viability  of  a  fragment  of  bone  to  remove  it. 
The  deep  fascia  may  need  division  to  permit  of  a  view  of  the 
depths  of  the  wound.  The  fractured  bones  are  then  to  be  approx- 
imated and  sutured,  if  practicable.  The  corners  of  the  wound 
may  be  sutured.  It  is  wise  to  leave  the  wound  open  enough  to 
receive  several  temporary  gauze  wicks  for  drainage  during  the 
first  few  days.  Counteropenings  may  be  needed  if  one  is  not 
sure  of  the  aseptic  condition  of  the  wound.  They  do  no  harm 
and   may  prove   safety-valves   against   latent   infection.      Before 


Fig.  527. — Lateral  view  of  figure  526.     Note  discharging  sinuses. 


leaving  the  wound  it  should  be  thoroughly  douched  with  boiled 
water.  An  aseptic  dressing  is  applied,  and  the  leg  is  immobilized 
by  the  posterior  wire  and  side  splints  (see  Figs.  523,  524)  or  is  put 
up  immediately  in  a  plaster-of-Paris  splint.  If  the  plaster-of-Paris 
splint  is  used,  a  window  should  be  cut  in  it,  through  which  the 
wound  may  be  dressed. 

Case  of  a  Fracture  of  the  Leg  after  the  Permanent  Dress= 
ing  has  heen  Applied. — All  fractures  of  the  leg  will  be  placed, 
sooner  or  later,  in   the   fixed   plaster-of-Paris   splint.      One  week 


TREATMENT 


373 


after  the  splint  is  applied  the  patient  may  be  up  and  about  with 
crutches.  At  first,  the  hanging  of  the  leg  down  may  be  attended  by 
great  discomfort.  There  may  be  a  sense  of  fullness  and  of  burn- 
ing in  the  leg.    The  leg  may  feel  as  if  it  would  burst.    The  toes  may 


Fig.  528. — Ligaments  of  normal  ankle.    The 
mortise  for  the  astragalus  is  seen. 


Fig.  529. — Pott's  fracture  (diagram). 
Fracture  of  fibula,  tear  of  the  internal 
lateral  ligament.  Displacement  outward 
of  foot.  A  sliding  of  the  astragalus  upon 
the  articular  surface  of  the  tibia  without  a 
tilting  of  the  astragalus  upon  its  antero- 
posterior axis. 


look  blue  and  be  swollen.  As  the  patient  becomes  accustomed 
to  these  conditions,  which  are  in  themselves  harmless,  he  will  be 
able  to  ignore  them  ;  they  will  grow  less  and  less  troublesome, 
and  eventually  disappear.      At  the  end  of  four  or  five  weeks  the 


374 


FRACTURES    OF    THE    LEG 


fracture  should  be  found  firmly  united.  A  lighter  plaster  splint  may 
be  applied,  extending  only  to  the  knee-joint,  and  allowing  flexion 
of  the  knee.  This  thin  plaster  splint  should  be  split,  so  as  to  be 
removable.  After  about  four  weeks  the  leg  should  then  receive 
a  daily  bath  and  massage,  with  active  and  passive  motion  to  the 
knee-joint.  At  about  the  eighth  week  the  protecting  splint  may 
be  removed,  a  flannel  bandage  from  the  toes  to  the  knee  substi- 
tuted, and  the  patient  be  allowed  to  touch  the  foot  to  the  floor, 
bearing  a  little  weight.  As  soon  as  the  plaster  is  removed  and 
the  bandage  substituted,  a  shoe,  preferably  laced,  should  be 
worn    on     that    foot.      From    the    tenth    to     the    twelfth    week 


Fig.  530. — Case:  Open  Pott's    racture.     Wound  in  soft  parts  and  protruding  tibia  to  be  seen. 


after  the  injury  the  patient  should  be  walking  with  a  cane. 
According  to  present  methods,  a  fractured  leg  would  require 
from  three  to  five  months  of  treatment  before  restoration  to 
normal  function  is  completed. 

The  after-care  of  a  case  of  fracture  of  the  leg  is  attended 
with  no  little  anxiety  on  the  part  of  the  surgeon.  The  general 
health  of  the  patient  is  a  matter  of  considerable  concern.  The 
loss  of  exercise  entailed  by  the  cramped  and  unnatural  position 
1  .iiisrs  loss  of  appetite,  headache,  constipation,  dyspeptic  ills, 
etc.  The  pain  through  the  whole  limb,  due  undoubtedly  to  the 
sprain  and  wrenching  at  the  time  of  the  injur}-,  the  aching  at 
night  at  tin-   seal  of  the   fracture,  combine  to  render  the  patient 


TREATMENT 


375 


thoroughly  uncomfortable, unhappy,  and  even  melancholy.  Pres- 
sure spots  will  appear  about  the  most  carefully  applied  bandage, 
and  they  must  receive  attention.  Itching  of  the  skin  inside  the 
splints  is  sometimes  almost  unendurable.      To  every  patient  daily 


Fig-  531.— Normal  leg  and  foot  at  a  right  angle.     Note  the  relative  position  of  heel  and  leg. 


Fig.  532. — Pott's  fracture.  Posterior  displacement  of  the  foot  on  the  leg.  Note  the  short- 
ening of  the  foot  from  the  toe  to  the  front  of  the  ankle.  Compare  the  relative  position  of  the 
heel  and  leg  with  the  same  in  figure  531. 


general  and  local  massage  and  bathing  will  be  found  to  be  ol 
unspeakable  comfort.  The  average  hospital  patient  is  far  less 
sensitive  to  all  the  petty  annoyances  of  an  immovable  and  closely 
fitting  dressing  than  is  the  private  patient. 


376 


FRACTURES    OF    THE    LEG 


The  Prognosis. — In  children  and  young  people  the  minimum 
time  is  consumed  by  the  process  of  repair.  The  restoration  of 
the  leg  to  its  normal  function  is  more  rapid  than  in  the  cases  of 
adults,  and  there  are  fewer  complications.  In  adults  a  chronic 
arthritis  may  appear  in  the  neighboring  knee-  or  ankle-joints. 
Swelling  of  the  leg  and  ankle  may  persist  for  some  time.  Non- 
union of  the  bones  may  result,  and  necessitate  operative  meas- 
ures (see  Fig.  525).  If  the  fracture  is  oblique,  shortening  may 
occur  even  after  union  takes  place  if  the  unsupported  leg  is  used 
too  soon  and  too  much.      If  the  wound  of  an  open  fracture  heals 


Fig.  531,. — Line  of  measurement  to  detect  backward  displacement  of  the  foot  on  the  leg. 


quickly,  and  there  is  little  comminution  of  bone,  repair  will  take 
place  as  in  a  closed  fracture.  Otherwise,  an  open  fracture  will 
unite  more  slowly  than  a  closed  fracture.  Persistent  swelling 
of  the  leg,  particularly  about  the  ankle,  is  associated  with  the 
convalescence  from  an  open  fracture.  Necrosis  of  bone  at  the 
seat  of  fracture  may  occur  in  cases  of  open  fracture  even  many 
months  or  years  after  the  original  injury.  Abscesses  and  sinuses 
may  form,  necessitating  operation  for  the  removal  of  the  necrosed 
bone  (see  Figs.  526,  527).  If  the  fracture  is  near  the  knee-  or 
ankle-joints,  the  prognosis  is  more  uncertain  than  if   the  fracture 


RESULTS    AFTER    TREATMENT 


377 


is  at  the  center  of  the  shaft.  A  comminuted  fracture  is  more 
likely  to  be  longer  in  uniting  and  to  give  rise  to  trouble  after 
repair  than  is  a  single  transverse  fracture. 

Results  after  Fracture  of  the  Leg. — Of  value  in  this  con- 
nection are  the  results  following  fracture  of  the  leg  in  thirty-five 
cases  treated  at  the  Massachusetts  General  Hospital,  and  exam- 
ined one  and  a  half  to  ten  years  after  the  accident.      In  the  de- 


Fig.  534. — Pott's  fracture  of  left  ankle.    Method  of  examining  ankle.    Lateral  mobility  shown. 
Note  the  grasp  of  the  foot  and  the  leg. 


tailed  report  of  these  cases  the  exact  lesion  and  its  seat  will  be 
stated.  In  thirteen  cases — in  ten  of  which  the  age  was  forty-two, 
the  rest  under  thirty — the  result  reported  was  that  the  injured 
leg  was  "as  good  as  the  other  leg."  In  twenty-two  cases  the 
result  was  a  leg  permanently  impaired  in  some  particular.  Some 
cases  had  flat-foot,  deformity  of  the  leg,  limited  motion  at  the 
knee-joint,  lameness,  necrosis  of  bone,  pain  in  the  fracture  when 
the  weather  was  damp.      Other  cases  had  pain  in  the  leg  upon 


37$ 


FRACTURES    OF    THE    LEG 


standing,  stiffness  of  the  ankle,  pain  upon  stepping  on  uneven 
surfaces,  weakness  of  the  leg,  swelling  of  the  leg  and  foot,  cramps 
at  night  in  the  calf  of  the  leg,  or  some  combination  of  these 
symptoms. 

Thrombosis  and  Embolism. — Thrombosis  of  the  veins  about 
a  fracture,  and  particularly  about  a  fracture  in  which  there  is 
some  laceration  of  the  soft  parts,  is  not  at  all  uncommon.  At 
times,  and  rather  more  frequently  than  is  generally  supposed, 
emboli  are  detached  from  these  thrombi  and  cause  almost  im- 
mediate death,  with  symptoms  of  pulmonary  embolism — namely, 
a  sudden  cyanosis  and  great  difficulty  in  breathing  associated 
with  intense  precordial  distress. 


Fig.  535. — Case:  Fracture  of  the  internal  and  external  malleoli  and  displacement  of  the  foot 

inward  and  backward. 


Thrombosis  of  the  veins  of  the  leg  or  thigh  is  undoubtedly 
one  of  the  causes  of  the  great  edema  seen  after  fracture  ot 
these  parts. 

Refracture  of  the   Bones  of  the  Lower  Extremity. — It  is  not 

an  uncommon  experience  to  find  that  a  patient  with  a  fracture 
of  the  thigh,  leg,  or  patella  refractures  the  partially  united  bone. 
This  refracture  is  due  to  either  muscular  violence  or  a  slight  fall. 
There  is  ordinarily  little  displacement  of  the  fragments.  The  cal- 
lus of  the  original  injury  holds  the  bones  quite  securely.  The 
leg  is  usually  bent  at  the  seat  of  the  fracture.  Refracture  is, 
therefore,  practically  a  fracture  of  callus.  This  accident  has 
even  occurred  while  the  patient  is  wearing  a  protective  splint  of 


POTT  S    FRACTURE 


379 


plaster-of- Paris.  Union  in  these  cases  is  much  more  rapid  than 
after  the  original  injury.  About  one-half  the  time  required  for 
union  of  the  original  fracture  is  necessary  for  union  of  the  re- 
fracture.  The  patient  may,  therefore,  be  much  encouraged,  for 
though  the  accident  of  refracture  is  a  disheartening  one,  yet  he 
will  not  be  obliged  to  look  forward  to  a  longr  confinement. 


Fig.  536. — Same  as  figure  535.      Lateral  displacement  of  foot  inward  (see  X-ray  tracing, 

Fig-  537)- 


POTT'S  FRACTURE 
Anatomy. — The  anatomical  relations  of  the  lower  ends  of 
the  fibula  and  tibia  and  the  astragalus  and  os  calcis  should  be 
kept  constantly  in  mind.  The  os  calcis  and  astragalus  are  held 
firmly  together,  forming  the  posterior  portion  of  the  foot.  The 
astragalus  rests  mortise-like  between  the  internal  and  external 
malleoli  (see  Fig.  528).     The  strength  of  the  inferior  tibiofibular 


38o 


FRACTURES    OF    THE    LEG 


articulation   depends   upon   the  strong  inferior  tibiofibular  liga- 
ments, particularly  upon  the  interosseous  ligament. 

By  Pott's  fracture  of  the  ankle  is  understood  the  injury  caused 
by  forcible  eversion  and  abduction  of  the  foot  upon  the  leg.  The 
lesions  which  may  be  present  in  this  fracture  are  a  rupture  of  the 
internal  lateral  ligament,  a  fracture  of  the  tip  of  the  internal 
malleolus,  a  separation  of  the  lower  tibiofibular  articulation,  an 
oblique  fracture  of  the  fibula  two  or  three  inches  above  the  tip 
of  the  external  malleolus,  a  fracture  of  the  outer  edee  of  the 


Internal  malleolus. 


Internal  malleoli. 


1 

F'K-  537- — Fracture  of  both  malleoli  (anteroposterior  view).    Inversion  of  foot  (X-ray  tracing). 


lower  end  of  the  tibia.  Ordinarily,  the  mechanism  of  the  frac- 
ture is  somewhat  as  follows  :  As  the  foot  is  abducted,  the  strain 
is  felt  at  the  internal  lateral  ligament  and  at  the  inferior  tibio- 
fibular interosseous  ligament,  and  these  give  way.  If  the  force 
continues,  the  fibula  breaks  (see  Fig.  529).  If  the  force  still 
continues,  the  internal  malleolus  is  pushed  through  the  skin, 
and  an  open  fracture  results  (see  Fig.  530).  If  the  internal 
lateral  ligament  holds  against  this  lateral  force,  the  tip  of  the 
internal  malleolus  may  be  pulled  off. 


POTTS    FRACTURE  3 Si 

Symptoms. — The  ankle  presents  a  very  constant  appear- 
ance after  this  fracture.  A  traumatic  synovitis  exists.  Great 
swelling  appears,  at  first  chiefly  upon  the  inner  side  of  the  ankle. 
The  ankle-joint  becomes  distended  with  blood  and  serum.  All 
the  natural  hollows  about  the  joint  are  obliterated.  The  foot  is 
everted,  appearing  to  have  been  pushed  bodily  outward.  The 
internal  malleolus  is  unduly  prominent.  Some  of  this  promi- 
nence is  masked  by  the  swelling.  The  bony  connections  and 
natural  support  of  the  foot  having  been  removed,  the  foot  drops 


-  Tibia. 


Cuboid 


Fig.  538. — Fracture  of  the  tip  of  each  malleolus.     Dislocation  of  the  foot  backward.    Note  the 
prominence  in  front  of  the  ankle.     Same  case  as  figure  537  (X-ray  tracing). 


backward,  partly  because  of  the  pull  of  the  calf-muscles  but 
chiefly  because  of  its  own  weight  (see  Figs.  531,  532).  The 
deformity,  therefore,  is  a  double  one,  a  lateral  sliding  of  the  foot 
outward  and  an  anteroposterior  dropping  of  the  foot  backward. 
The  malleoli  are  spread  apart  :  the  measured  distance  between 
them  is  increased  over  the  normal.  Palpation  close  above  the 
anterior  articular  edge  of  the  tibia  and  the  astragalus  reveals  ten- 
derness over  the  ruptured  tibiofibular  ligament.  The  backward 
displacement  is  best  measured  by  the  length  of  the  line  from  the 


382 


FRACTURES    OF    THE    LEG 


front  of  the  ankle  to  the  cleft  between  the  first  and  second  toes 
(see  Fig.  533).  This  line  will  be  found  shortened  upon  the 
injured  side.  There  is  tenderness  over  the  fracture  of  the  fibula. 
If  the  internal  malleolus  is  fractured,  the  sharp  ridge  at  the  broken 
edge  can  be  distinctly  felt.  Grasping  the  posterior  part  of  the 
foot  firmly  with  the  whole  hand  while  the  other  hand  steadies 
the  lower  leg  just  above  the  ankle,  abnormal  lateral  mobility  of 
the  foot  may  be  detected  (see  Fig.  534).  The  foot  will  be  felt 
to  move  inward  to  its  natural  position.  The  moment  inward 
pressure  is  removed  the  foot  will  be  seen  and  felt  to  slump  out- 
ward aeain. 


Diaphysis  of  fibula. 


Epiphysis. 


Diaphysis  of  tibia. 


Epiphysis. 

Astragalus. 


Fig.  539. — Normal  ankle-joint,  showing  epiphyses  (anteroposterior  view). 


Figures  535—538  inclusive  illustrate  a  reversed  Pott's  de- 
formity, the  foot  having  moved  inward  instead  of  outward  as 
well  as  having  fallen  backward. 

Treatment. — The  indications  for  treatment  are  to  place  the 
parts  in  their  normal  relations,  and  to  maintain  them  so  until 
repair  is  completed,  guarding  against  both  the  lateral  and  the 
posterior  deformities.  If  for  any  reason,  such  as  the  presence 
of  very  great  swelling  of  the  ankle,  it  is  expedient  to  delay  re- 
duction, the  leg  should  be  placed  temporarily  in  a  pillow  and 
side  splints  (see  Figs.  504,  505,  506).  An  anesthetic  should 
always   be   administered    before    the    reduction    of  this   fracture. 


Upper  end  of  lower  frag- 
ment of  fibula. 


Astragalus. / 


Tibia. 


Internal  malleolus. 


Fig.   540. —  Pott's   fracture   (anteroposterior  view).      Notice  sliding  of  astragalus  outward 
Fracture  of  internal  malleolus.    Fracture  of  fibula.    Extreme  deformity  (X-ray  tracing). 


Lower  fragment  of  fibula. 


'Fibula. 

'  Tibia. 


\ 
\ 

Os  calcis. 
Fig.  541. — Pott's  fracture.     Same  as  figure  540  (lateral  view). 


3S3 


3§4 


FRACTURES    OF    THE    LEG 


The  reduction  is  thus  rendered  painless  and,  through  relaxation 
of  the  muscles,  is  made  far  easier.  The  principles  of  the  old 
Dupuytren  splint  are  the  ones  to  be  applied  in  the  reduction  of 


L Fracture  of  fibula. 


Fracture  of  interna] 

malleolus. 


Fig.  542.— Pott's  fracture.     Almost  no  displacement.    Compare  with  figure  540  (Massachusetts 
General  Hospital,  828.     X-ray  tracing). 


Fracture  of  fibula.  ■ 


Astragalus.   — 


—  Unusual  space. 

—  Internal  malleolus. 


Fig.  543. — Pott's  fracture.    Notice  sliding  of  astragalus  outward.    Fractures  of  internal  ma] 
leolus  and  fibula  (Massachusetts  General  Hospital,  548.    X-ray  tracing). 


this  fracture  whatever  the  apparatus  in  which  the  leg  is  perma- 
nently placed.  These  consist  of  tin-  making  of  lateral  outward 
pressure  upon  the  internal  malleolus,  lateral  inward  pressure  upon 


Astragalus 


—  Fracture  of  fibula. 


Fig.  544. — Pott's  fracture,  showing  fracture  of  the  fibula  and  but  slight  sliding  of  the 
astragalus,  a  sufficient  distance,  however,  to  have  made  a  rupture  of  the  internal  lateral  liga- 
ment highly  probable  (X-ray  tracing). 


Fig.  545. — Splintering  of  the 
lower  end  of  fibula  (Massachu- 
setts General  Hospital,  1105. 
X-ray  tracing). 

25 


Seat  of 
fracture. 


Fig.  546. — Fracture  of  the  internal  malleolus  (Massa- 
chusetts General  Hospital,  10S4.     X-ray  tracing). 


58S 


386 


FRACTURES    OF    THE    LEG 


the  foot,  and  a  forward  lift  upon  the  posterior  part  of  the  foot  or 
heel.  The  practitioner  may  very  properly  use  the  Dupuytren 
splint.  It  is  thought  to  be  uncomfortable,  but  it  is  not  if  prop- 
erly applied.  It  is  very  efficient  in  holding  the  fracture  reduced. 
The  Dupuytren  Splint. —  This  is  a  board  from  one-quarter  to 
one-half  of  an  inch  thick,  long  enough  to  extend  from  the  middle 


Fig.  547. — Pott's  fracture.     Dupuytren's  splint.     Note  length  ol   splint;   position  of  straps 
arrangement  <>i  padding  ;  space  between  foot  and  splint. 


of  the  thigh  to  six  inches  below  the  sole  of  the  foot,  and  as  wide 
as  the  calf  of  the  leg  from  front  to  back  (see  Fig.  547).  At  its 
lower  or  foot  end  it  is  serrated  with  three  or  four  teeth,  as  seen  in 
the  illustration.  It  is  padded  with  folded  sheets,  so  that  when  it 
is  applied  to  the  inner  surface  of  the  limb,  the  padding  extends  to 
just  above  the  level  of  the  internal  malleolus,  the  serrated  end  of 


POTT  S    FRACTURE 


387 


the  splint  projecting'six  inches  below  the  sole  of  the  foot.  The  pad- 
ding,as  seen  in  the  illustration,  is  so  thick  at  the  lower  end  over  the 
internal  malleolus  that  sufficient  room  is  left  for  inversion  and  rota- 
tion of  the  foot  upon  its  anteroposterior  axis  without  its  impinging 
upon  the  splint  in  the  least.     The  splint  is  held  in  place  by  straps 


Fig.  54S. — Pott's  fracture.  Dupuytren's  splint. 
Note  serrations  of  splint  and  turns  of  bandage 
adducting  foot. 


Fig.  549. — Cabot  posterior  wire 
splint  bent  at  the  ankle  for  a  Pott's 
fracture  of  the  right  leg.  To  be  used 
to  assist  in  maintaining  adduction  of 
the  foot. 


and  buckles  :  one  is  placed  above  the  ankle,  one  above  the  knee, 
and  a  third  is  placed  at  the  upper  end  of  the  splint.  For  the 
proper  application  of  the  splint  an  assistant  is  needed.  The  splint 
is  applied  while  the  leg  rests  upon  the  bed.  An  assistant  steadies 
the  splint  and  the  leg  so  that  they  both  project  clear  of  the  foot 


388 


FRACTURES    OF    THE    LEG 


of  the  bed.  A  roller  bandage  is  then  applied  in  circular  turns 
about  the  ankle  and  splint  from  the  splint  toward  the  leg.  After 
two  circular  turns  are  made,  the  assistant  adducts  and  inverts  the 
ankle  and  foot,  and  this  position  is  held  by  the  third  turn  of  the 
bandage,  which  is  passed  around  the  forward  part  of  the  foot  and 
over  one  of  the  serrations  of  the  splint  (see  Fig.  548).  In  order  to 
hold  this  firmly  a  turn  is  then  taken  around  the  ankle.      A  figure 


Fig.  550. — Pott's  fracture.     Cabot  posterior  wire  splint  and  side  splints.     Note  position  of 
lateral  pads  and  twisted  foot-piece.    Side  splints  are  shown  unpadded  (diagram). 


of  eight  is  thus  applied  for  several  turns  about  the  foot  and  ankle, 
crossing  the  ankle  in  front  of  the  instep  at  each  turn.  Each  suc- 
ceeding turn  is  caught  by  the  succeeding  serration  of  the  splint. 
At  the  same  time  the  foot  is  lifted  forward  by  pressure  from  be- 
hind, and  this  forward  lift  is  maintained  by  circular  turns  of  the 
bandage.  The  whole  limb  is  placed  upon  pillows.  Thus,  the 
eversion  and  posterior  dropping  of  the  foot  are  corrected. 
This    splint    forms   a   good    temporary  or    emergency   dressing 


TREATMENT    OF    POTT'S    FRACTURE  389 

for  Pott's  fracture.  This  dressing  corrects  the  eversion,  but 
there  is  great  danger  that  the  foot  may  slump  backward 
unless  most  carefully  watched.  This  failure  to  hold  the  pos- 
terior displacement  corrected  is  the  defect  of  the  Dupuytren 
splint. 

The  Posterior  Wire  Splint  with  Curved  Foot=piece  (see 
Figs.  549,  550,  551). — The  posterior  wire  splint  extending  to 
the  middle  of  the  thigh  is  another  apparatus  used  in  treating 
Pott's  fracture.  The  foot-piece  should  be  twisted  at  the  ankle, 
so  as  to  hold  the  foot  when  inverted  (see  Fig.  549).  The  splint 
is  covered  and  padded  in  the  usual  way  (see  p.  360).  The 
patient  is  anesthetized.  The  leg  is  placed  upon  the  splint.  The 
foot  is  strongly  inverted  by  great  lateral  pressure  put  upon  the 


Fig.  551. — Pott's  fracture.  Cabot  posterior  wire  splint,  adapted  to  the  adducting  of  the 
foot.  See  figure  517  for  method  of  slingingfoot  and  preventing  its  backward  displacement 
(diagram). 


posterior  part  of  the  foot.  This  inversion  of  the  foot  can  not  be 
made  too  strongly,  for  the  deformity  can  not  be  overcorrected. 
The  position  of  extreme  inversion  is  not  a  painful  one  to  maintain. 
Ordinarily,  the  lateral  pressure  applied  is  too  slight  entirely  to 
correct  the  deformity.  The  foot  is  held  to  the  inverted  foot-piece 
by  straps  of  adhesive  plaster,  pads,  and  side  splints  (see  Fig.  550). 
A  pad  is  applied  to  the  sole  of  the  foot,  and  so  placed  as  to  main- 
tain the  long  anteroposterior  arch  of  the  foot.  It  is  found  that 
if  this  is  not  done,  there  is  considerable  flattening  of  this  arch 
upon  recovery.  The  forward  lift  upon  the  foot  is  made  and 
maintained  by  proper  padding  posteriorly  to  the  lower  leg  and 
just  above  the  heel  (see  Fig.  551).  The  lift  may  be  reinforced 
by  smoothly  applied  strips  of  adhesive  plaster  placed  laterally  on 


390 


FRACTURES    OF    THE    LEG 


the  foot  and  carried  under  the  heel  and  up  and  over  the  end  of 
the  foot-piece.  These  adhesive-plaster  strips  serve  as  a  sling  for 
the  foot.  There  is  one  other  way  to  avoid  pressure  upon  the 
point  of  the  heel,  and  that  is  by  placing  beneath  the  heel  a  ring 
of  sheet  wadding  covered  with  a  tightly  wound  bandage  (see 
Fig-  Sl7)-  These  methods  of  protecting  the  heel  from  pressure 
may  all  be  used  at  one  time  to  advantage.     The  side  splints  are 


Fig.  552. — Pott's  fracture.     Stimsoti's  splint.     Posterior  plaster  (represented  two  inches  too 
long  at  the  upper  end). 


applied  with  great  care,  being  so  padded  as  to  maintain  the  out- 
ward pressure  upon  the  inner  surface  of  the  lower  end  of  the  tibia, 
and  the  inward  pressure  upon  the  outer  surface  of  the  foot.  Very 
great  care  must  be  exercised  that  there  is  no  recurrence  of  the 
deformity.     Frequent  readjustments  are  necessary. 

The   Lateral   and    Posterior    Plaster=of=Paris   Splints  (Stim  = 
son's  Splint). — Tin:  posterior  splint  (see  Fig.  552)  extends  from 


TREATMENT    OF    POTT  S    FRACTURE 


391 


the  toes  along  the  sole  of  the  foot  around  the  back  of  the  heel 
and  up  the  back  of  the  leg  to  the  knee  or  to  the  middle  of  the 
thigh.  The  lateral  splint  (see  Fig.  553)  begins  at  the  external 
malleolus,  passes  over  the  dorsum  of  the  foot  to  the  inner  side 
under  the  sole,  and  upward  along  the  outer  side  of  the  leg  to  the 


Fig-  553- — Pott's  fracture.    Stimson's  splint  completed.     Lateral  plaster  and  posterior  plaster. 


same  height  as  the  posterior  splint.  Each  of  these  splints  is 
made  of  about  six  or  eight  strips  of  washed  crinoline,  four  inches 
wide  and  long  enough  to  extend  from  around  the  foot  to  the  bend 
of  the  knee  or  middle  of  the  thigh.  The  leg  is  protected  by 
roller  bandages  of  sheet  wadding.  Plaster  cream  is  rubbed  into 
the  crinoline  strips  one  after  the  other  until  all  the  strips  have 


392 


FRACTURES    OF    THE    LEG 


been  used.  The  posterior  splint  is  applied  first,  and  held  snugly 
by  a  gauze  bandage  to  the  leg  and  foot.  Then  the  remaining 
crinoline  strips  are  likewise  covered  with  plaster  cream  and 
applied  as  the  lateral  splint  (see  Fig.  554).  This  is  also  held 
snugly  by  a  gauze  bandage  to  the  leg  and  foot.  During  the 
application  of  the  splint  and  until  the  plaster-of- Paris  has  set, 
the  foot  should  be  held  in  a  corrected  position  by  an  assistant. 
These  two  plaster-of-Paris  splints  are  preferable  to  the  encircling 
plaster  splint,  the  ordinary  "  plaster  leg,"  for  by  their  use  the 
ankle  can  be  inspected.  Less  judgment  is  requisite  in  its 
application  to  insure  the  correction  of  the  deformity  than  by  the 


Fig.  554. — Pott's  fracture.     Stimsou's  splint  removed.     Lateral  and  posterior  plasters. 


use  of  the  ordinary  "plaster  splint."  As  the  swelling  subsides 
and  the  plaster  becomes  loose,  if  the  splints  are  kept  tight  by 
bandaging,  the  deformity  can  not  possibly  recur. 

Care  of  the  Fracture  after  the  Permanent  Dressing  is  Ap= 
plied. — If  the  posterior  and  side  splints  are  used  :  After  the 
initial  swelling  has  subsided — i.  c,  after  the  first  week — the  leq; 
may  be  placed  in  a  plaster-of-Paris  splint  (circular  bandage),  and 
the  patient  allowed  up  and  about  with  crutches.  The  plaster 
should  be  split  after  application  and  held  in  place  by  straps  or  a 
bandage  If  the  Stimson  splint  is  used,  the  patient  may  be 
allowed  up  and  about  with  crutches  at  the  end  of  the  first  week'. 


TKKATMENT    OK    POTTS    FRACTURE 


393 


Massage  may  be  applied  to  the  exposed  parts  of  the  leg  and 
foot  daily.  At  the  third  week  all  dressings  should  be  removed, 
and  gentle  massage  applied  to  the  whole  leg  from  toes  to 
groin,  especial  attention  being  paid  to  the  region  of  the  ankle. 
Massage  and  gentle  passive  motion  in  an  anteroposterior  direc- 
tion only  should  be  applied  at  least  once  or  twice  daily  after  the 
second  week.  All  lateral  motion  is  to  be  avoided.  After  the 
fifth  or  sixth  week  a  flannel  bandage  will  be  all  the  support 
needed,    although   comfort  may  demand   a  thin,   stiff,   retentive 


Fig-  555- — Pad  and  adhesive-plaster 
strap  to  maintain  the  arch  of  the  foot  after 
fracture. 


Fig.  556. — Adhesive-plaster  strap  to 
prevent  inversion  of  the  foot  in  fractures 
of  the  external  malleolus. 


splint  at  times.      At  the  end  of  two  months  some  weight  may  be 
borne  upon  the  foot. 

Of  the  three  methods  of  dressing  a  Pott's  fracture  the  posterior 
and  lateral  plaster  splint  of  Stimson  is  by  far  the  simplest,  and  it 
is  efficient  in  every  way.  Moreover,  it  allows  of  massage  being 
instituted  early  with  the  least  disturbance  to  the  ankle.  The 
posterior  wire  splint  is  more  difficult  of  application,  and  needs 
careful  watching  and  frequent  readjustment.  With  the  posterior 
wire  splint  in  use  the  foot  or  leg  is  easily  accessible  to  early 
massage  by  simply  loosening  the  side  splints. 


394  FRACTURES    OF    THE    LEG 

Prognosis  and  Results. — In  young  adults  there  should  be  no 
deformity  and  almost  no  permanent  disability.  In  adults  there 
will  be  some  stiffness  for  a  time.  If  the  lateral  deformity  has  not 
been  completely  corrected,  a  traumatic  pronation  of  the  foot  will 
result.  The  longitudinal  arch  of  the  foot  should  be  supported 
always  by  a  suitable  pad  under  the  instep  for  at  least  six  months 
following  this  fracture,  whether  there  is  deformity  or  not  (see 
Figs.  555,  556).  If  there  is  deformity,  it  will  relieve  the  pain. 
An  insole  of  leather  with  a  pad  stitched  to  it  for  support  to  the 
arch  of  the  foot  is  often  of  great  service.  If  there  is  no  pain  or 
deformity,  it  will  strengthen  the  foot  until  walking  is  easy  again, 
and  will  prevent  deformity  appearing.  If  the  anteroposterior 
deformity  has  not  been  corrected,  pain  may  be  experienced  upon 
using  the  foot.  The  foot  is  shortened  and  dorsal  flexion  is  much 
hindered,  so  that  the  gait  is  decidedly  impaired.  The  patient  will 
walk  with  a  more  or  less  stiff  ankle.  In  those  cases  in  which 
there  is  great  deformity  associated  with  extensive  laceration  of 
the  soft  parts,  the  foot  and  ankle  may  for  many  weeks  subsequent 
to  union  be  painful,  stiff,  and  swollen.  Pain,  stiffness,  and  swell- 
ing increase  with  the  age  of  the  patient — i.  e.,  the  younger  the 
patient,  the  less  discomfort  will  there  be  following  this  fracture. 

The  Operative  Treatment  of  Old  Pott's  Fractures. — The  in- 
dications for  operation  will  be  persisting  lateral  or  backward  dis- 
placements. The  only  method  for  the  relief  of  these  deformities 
is  by  osteotomy  of  the  tibia  and  fibula.  The  results  following 
this  operation  are  satisfactory. 

Open  Pott's  Fracture  (see  Fig.  530). — The  ankle-joint  is 
involved.  Two  things  are  to  be  considered  in  deciding  upon 
the  treatment  of  the  injury — the  extent  of  the  laceration  of  the 
soft  parts  and  the  amount  of  injury  to  the  bones.  If  the  lacera- 
tion is  so  great  that  the  foot  is  useless,  amputation  is  indicated. 
Amputation  is  indicated  in  only  two  other  instances — old  age 
and  sepsis.  If  the  laceration  is  not  great,  and  any  existing 
dislocation  can  be  reduced,  it  should  be  reduced  without  excision, 
proper  drainage  being  provided,  both  anteriorly  and  posteriorly, 
to  the  joint.  If  the  laceration  is  not  great  and  reduction  of  the 
deformity  is  impossible,  then  cither  partial  or  complete  excision 
should  be  done.      If  there  is  great  injury  to  bone,  whether  the 


OPEN    POTTS    FRACTURE  395 

dislocation  can  or  can  not  be  reduced,  a  partial  or  complete  ex- 
cision should  be  done.  In  every  open  Pott's  fracture,  no  matter 
how  small  the  wound  of  the  soft  parts,  in  order  to  insure  an 
aseptic  wound  it  should  be  enlarged  sufficiently  for  thorough 
cleansing  with  antiseptic  solutions  in  every  part.  Extreme  con- 
servatism should  characterize  the  treatment  of  recent  open  Pott's 
fracture.  In  the  large  majority  of  cases  treated  upon  the  con- 
servative or  expectant  plan  a  useful  ankle-joint  and  foot  will 
result.  The  older  the  adult  patient  is,  the  more  radical  must  be 
the  treatment. 


CHAPTER  XV 
FRACTURES  OF  THE  BONES  OF  THE  FOOT 

Fracture  of  the  astragalus  is  caused  by  a  blow  on  the  sole 
of  the  foot,  as  in  a  fall  from  a  height  (see  Fig.  557).  Fracture  of 
the  os  calcis  is  often  present  in  the  same  foot  with  fracture  of  the 
astragalus.  The  ankle-joint  may  or  may  not  be  involved.  The 
diagnosis  is  difficult  without  the  use  of  the  Rontgen  ray.  Crep- 
itus  may  be  elicited.     Great  swelling  may  appear  in  the  region 


Tibia. 


Line  of  fracture 


N     / 

Head  and  neck  ^y 

of  astragalus.  /    \ 

Cuneiform.      Scaphoid.     \  / 


External 

— 1 malleolus. 

Body  of  astrag- 
alus. 


Os  calcis. 


Cuboid. 


Fig.  557. — Fracture  of  the  neck  of  the  astragalus  (X-ray  tracing). 


of  the  fracture.  It  is  highly  probable  that  many  cases  of  sprained 
ankle  have  been  cases  of  fracture  of  the  astragalus.  If  there  is 
no  displacement,  treatment  will  consist  in  immobilizing  the  ankle- 
joint  with  the  foot  held  at  a  right  angle  with  the  leg.  As  soon 
as  the  swelling  has  begun  to  subside,  massage  may  be  used  to 
advantage  and  convalescence  be  thus  hastened.  The  most  satis- 
factory dressing  is  a  plaster-of-Paris  splint  extending  from  the 
toes  to  below  the  knee,  applied  and  immediately  split  open,  so  as 

396 


FRACTURE    OF    THE    OS    CALCIS 


397 


to  form  a  removable  splint.  This  may  be  taken  off  for  massage 
and  passive  motion.  Recovery  takes  place  with  fair  movement 
at  the  ankle-joint,  so  that  after  from  two  months  and  a  half  to 
three  months  the  patient  can  walk  without  support.      After  this 


External  malleolus. 


Posterior  fragment  / 

of  os  calcis.       y 
Inferior  fragment  v  yC 

of  os  calcis.  \  / 

/ 
I 
I 
I 
v 


Tibia. 


,  I  li      S  Anterior  fragment 

of  os  calcis. 


Fig.  558. — Fracture  of  the  os  calcis  in  the  body  of  the  bone  (X-ray  tracing). 


Line  of  fracture. 

Fig.  559. — Fracture  of  the  os  calcis,  almost  transversely  across  the  junction  of  the  body  and 

neck  (X-ray  tracing). 


time  complete  recovery  is  slow.      More  or  less  stiffness  and  pain 
may  exist  for  four  or  six  months  after  the  accident. 

Fracture  of  the   Os   Calcis. — The  os  calcis  is  fractured  by 
a  fall  on  the  sole  of  the  foot,  as  well  as  by  a  powerful  contrac- 


39§ 


FRACTURES    OF    THE    IJONES    OF    THE    FOOT 


tion  of  the  gastrocnemius  muscle  and  strong  tension  upon  the 
tendo   Achillis.      It  may  be  crushed,   fractured   transversely  or 


Place  of  frac- I 

ture.  1 


Fig.  560. — Fracture  of  the  left  os  calcis  through  the  body  of  the  bone  (X-ray  tracing). 


_i Astragalus. 


—  Line  of  fracture. 


Fig.  5,61 . — Fracture  of  the  os  calcis.     The  part  torn  oil  is  that  to  which  is  attached  the  tendo 
Achillis.     Notice  displacement  (Massachusetts  General  Hospital,  1652.  X-ray  tracing). 


longitudinally,  or  a  piece  may  be  torn  off  from  its  posterior  por- 
tion mar  the  insertion  of  the  tendo  Achillis  (see  Figs.  558—563 
inclusive).      The  symptoms  of  fracture  will  be  the  usual  ones  of 


TREATMENT 


399 


crepitus,  swelling,  pain,  abnormal  mobility.     The  heel  is  seen, 
by  comparison  with  its  uninjured  fellow,  to  be  enlarged.      This 


Body  of  astragalus. 1 


Neck  of  astragalus.  ^J-\ 

/ 
/ 


External  malleolus. 


' -V  -\ — .  Os  calcis. 


_'i_Os  calcis,  posterior 
fragment. 

,      Os  calcis,  anterior 
7 fragment. 


Fig.  562. ^Fracture  of  the  right  os  calcis.     Same  patient  as  figure  557. 


Upper  border  of os 
calcis. 


Os  calcis.  • 


Fig.  563.— Fracture  of  the  os  calcis  without  great  displacement  (Massachusetts  General 
Hospital,  102.     X-ray  tracing). 


fracture  is  sometimes  associated  with  fracture  of  the  astragalus 
(see  Fig.  564).  The  treatment  is  to  immobilize  the  foot  at  the 
angle  that  will  best  hold  the  fragments  approximately  in  appo- 


4-00         FRACTURES  OF  THE  BONES  OF  THE  FOOT 

sition.  Complete  plantar  flexion  of  the  foot  may  be  needed  to 
bring  the  fragments  well  into  position.  The  pull  upon  the  tendo 
Achillis  is  in  this  position  removed  from  the  posterior  fragment. 
Massage  should  be  instituted  early — during  the  first  week.  The 
removable  plaster-of- Paris  dressing  is  the  best  form  of  splint. 
After  three  weeks  the  splint  should  be  removed,  and  a  close 
fitting  flannel  bandage  applied,  with  small  pads  under  the  mal- 
leoli and  on  each  side  of  the  tendo  Achillis.  The  pads,  if  applied 
with  considerable  pressure,  will  assist  very  materially  in  reducing 
the  swelling  and  in  restoring  form  to  the  ankle.  It  will  be  about 
two  months  before  the  patient  should  bear  much  weight  upon  the 
foot.      After  three  to  four  months  walking  will  be  comparatively 


Fig.  564.— Case  :  Posterior  view  of  fiacture  of  right  os  calcis  and  of  left  astragalus.    Deformity. 
Note  fullness  each  side  of  the  tendo  Achillis  (see  X-ray  tracings  557  and  562). 

easy.  It  is  often  the  case  after  fracture  of  the  os  calcis  and 
also  after  fracture  of  the  astragalus  that  there  is  considerable 
disturbance  of  the  normal  mechanism  of  the  foot.  A  traumatic 
flat-foot  results  from  the  accident.  This  can  be  greatly  relieved 
by  the  introduction  into  the  shoe  of  a  leather  pad,  to  raise  the 
instep  and  take  the  strain  off  the  injured  part.  The  patient  may 
find  that  for  a  period  of  six  months  or  more  the  wearing  of  this 
pad  is  a  great  support  and  comfort.  The  hot-air  baking  is  very 
satisfactory  for  the  relief  of  the  pain  and  stiffness  felt  throughout 
the  ankle  and  foot.  The  hot-air  treatment,  combined  with  mas- 
sage, helps  to  hasten  convalescence.  This  treatment  should  be 
used  once  daily  until  the  pain  in  the  foot  has  disappeared. 


FRACTURE    OF    THE    METATARSUS 


40I 


Open  fracture  of  the  astragalus  and  os  calcis  if  treated 
antiseptically,  recovers  with  a  useful  ankle  and  foot  even  though 
the  ankle-joint  is  ankylosed.  The  mediotarsal  joint  becomes 
more  flexible  than  it  ordinarily  is.  The  loss  of  motion  at  the 
ankle-joint  is  compensated  for  by  the  mediotarsal  joint  motion, 
and  the  individual  may  walk  with  hardly  a  perceptible  limp. 
Removal  by  operation  of  the  fractured  bone  is  attended  by  good 
functional  results,  and  if  the  bone  is  much  comminuted  or  dislo- 
cated, operation  is  indicated. 


Fig.  565. — Metatarsus  and  phalanges,  showing  epiphyses  at  fifteen  years  (Warren  Museum, 

specimen  537). 


Fig.  566.— Fracture  across  the  first  metatarsal  of  the  right  foot  (X-ray  tracing 


Fracture  of  the  Metatarsal  Bones  (see  Fig.  565). — This  frac- 
ture is  caused  by  direct  violence.  The  first  and  fifth  bones  are 
the  ones  most  often  broken  (see  Fig.  566).  The  symptoms  are 
swelling,  pain,  crepitus,  and  abnormal  mobility.  The  weight  can 
not  be  borne  upon  the  foot  without  pain.  There  is  never  great 
displacement.  In  order  to  avoid  trouble  in  walking  after  union 
has  occurred,  it  is  wise  to  make  the  approximation  of  the  frag- 
ments as  nearly  accurate  as  possible.  A  closed  or  simple  frac- 
ture is  ordinarily  uncomplicated.  Union  takes  place  in  from 
26 


402 


FRACTURES  OF  THE  BONES  OF  THE  FOOT 


three  to  four  weeks.  It  will  be  at  least  from  two  to  four  months 
before  the  foot  can  be  used  without  thought  of  the  injury  received. 
If  the  fracture  is  open,  repair  will  be  slower  than  after  a  closed 
fracture.  If  the  wound  is  kept  clean  and  free  from  infection,  no 
complications  will  arise.  If,  on  the  other  hand,  the  wound  be- 
comes infected,  necrosis  of  bone,  abscess  formation,  burrowing 
of  pus,  and  great  swelling  of  the  foot  may  occur,  all  of  which 
will  greatly  delay  the  healing  process.  The  foot  should  be 
immobilized  by  a  lateral  molded  splint  of  plaster-of- Paris.  This 
should  be  placed  upon  either  the  outer  or  inner  side  of  the  ankle, 
according  as  the  outer  or  inner  metatarsals  are  broken.      The 


Fig.  567.— Fracture  of  the  first  phalanx  of  the  little  toe  (Massachusetts  General  Hospital,  115. 

X-ray  tracing). 


splint  should  extend  from  the  middle  of  the  calf  of  the  leg  to  the 
tips  of  the  toes.  It  is  held  in  position  by  a  roller  bandage  of  gauze. 
Fracture  of  the  Phalanges  of  the  Foot. — These  fractures 
are  rather  unusual,  except  from  a  crush  of  the  foot  (see  Fig. 
567).  They  are  sometimes  open.  The  same  general  rules  of 
treatment  apply  to  fractures  of  these  bones  as  to  fractures  of  the 
phalanges  of  the  hand.  A  simple  plantar  splint  of  splint  wood, 
padding  of  the  toes,  and  adhesive-plaster  straps  will  be  sufficient 
to  hold  the  fracture.  If  the  plantar  splint  covers  the  entire  sole 
of  the  foot,  it  will  prove  of  great  comfort.  It  is  sometimes  wise 
to  immobilize  the  ankle-joint  by  the  thin  plaster  side  splint,  par- 
ticularly if  there  is  swelling  of  the  leg  and  ankle. 


CHAPTER  XVI 
ANATOMICAL  FACTS  REGARDING  THE  EPIPHYSES 

Hitherto  our  knowledge  of  injuries  to  the  epiphyses  has  been 
obtained  mainly  through  clinical  and  pathological  observation. 
This  knowledge  is  only  approximately  correct.     With  the  assist- 


L-^-sa, 


Fig.  569. — Relation  of  the  capsule  of  the 
shoulder-joint  to  the  upper  epiphyses  of  the 
humerus  (diagram). 


Fig.  568. — Epiphyses  of  humerus  at 
eight  jears  (Warren  Museum,  specimen 
334)- 


Fig.  570. —  Relation  of  the  capsule  of  the 
knee-joint  to  the  patella,  femur,  and  tibia 
(diagram). 


ance  of  the  Rontgen  ray  a  very  great  advance  is  being  made  in 
the  accuracy  of  our  knowledge  of  the  epiphyses.  Whereas  there 
will,  perhaps,  always  exist  differences  in  the  times  of  the  appear- 
ance of  the  ossification  centers  and  the  times   of  union  of  the 

403 


4O4  ANATOMICAL    FACTS    REGARDING    THE    EPIPHYSES 

epiphyses,  the  discrepancies  in  each   observer's   series   of  cases 
will  grow  less  and  less. 

The  importance  of  an  exact  knowledge  of  the  epiphyses  to 
those  having  to  do  with  injuries  in  the  neighborhood  of  joints  is 
undoubted.  The  diagnosis,  prognosis,  and  treatment  of  joint 
injuries  and  injuries  in  the  immediate  vicinity  of  joints  is  far 
more  satisfactory  than  ever  before.  The  book  by  John  Poland 
upon  "Traumatic  Separation  of  the  Epiphyses,"  from  which  the 
following  data  are  largely  taken,  marks  an  era  in  this  branch  of 
surgery.  Only  those  facts  that  are  considered  especially  impor- 
tant for  practical  everyday  use  are  here  mentioned. 


THE  DATE  OF  THE  APPEARANCE  OF  OSSIFICATION  IN  THE 
CHIEF  EPIPHYSES  OF  THE  LONG  BONES 

{After  Poland) 

,  .    ,  (   Lower  end  of  femur. 

At  birth {    TT  ,     .    .,  . 

I.   Upper  end  of  tibia. 

f   Upper  end  of  femur. 

At  one  year \ 

(.  Upper  end  of  humerus. 

,    ,r  f  Lower  end  of  tibia. 

At  one  and  one-balf  years < 

{.  Lower  end  of  humerus. 

f   Lower  end  of  radius. 

At  two  years J. 

I  Lower  end  of  fibula. 

,      .  f  Great  trochanter  of  femur. 

At  three  years •< 

I  Great  tuberosity  of  humerus. 

.  .  c  (  Upper  end  of  ulna. 

At  four  years <       rr 

t   Upper  end  of  fibula. 

From  five  to  six  years -!    Upper  end  of  radius. 


Lower  end  of  ulna. 


°      *  '    '    '    '    \  Lesser  trochanter  of  femur. 

After  a  most  exhaustive  study  of  pathological  and  clinical 
material,  both  of  his  own  and  that  of  other  observers,  Poland 
concludes  that  the  order  of  frequency  of  separation  of  the  epiphy- 
ses is  about  as  follows  : 

1.  The  upper  epiphysis  of  the  humerus. 

2.  The  lower  epiphysis  of  the  femur. 

3.  The  lower  epiphysis  of  the  radius. 

4.  The  lower  epiphysis  of  the  humerus. 

5.  The  lower  epiphysis  of  the  tibia. 

6.  'I  he  upper  epiphysis  of  the  tibia. 


THE    LOWER    EPIPHYSIS    OF    THE    FEMUR 


405 


The  upper  epiphysis  of  the  humerus  is  composed  of  three 
separate  centers  of  ossification  :  That  for  the  head,  appearing 
at  two  years  ;  that  for  the  great  tuberosity,  appearing  at  three 
years  ;  that  for  the  lesser  tuberosity,  appearing  at  four  years. 
These  three  centers  coalesce  to  form  the  upper  epiphysis,  and 
it  unites,  at  from  the  twentieth  to  the  twenty-fourth  year,  to  the 
diaphysis  of  the  humerus  (see  Fig.  568).  (For  Separation  of 
this  Epiphysis  see  p.  128.) 


Fig.  571.— Relation  of  the  capsule  of  the  knee-joint  to  the  lower  epiphysis  of  the  femur  and  the 
upper  epiphysis  of  the  tibia  (diagram). 


<?*U 


Fig.  572.— Epiphyses  at  the  wrist  at  seventeen  years:  a,  Ulna;  b,  posterior  surface  of  the 
radius  ;  c,  anterior  surface  of  the  radius  (Warren  Museum,  specimen  447). 


Separation  of  the  upper  humeral  epiphysis  will  not  necessarily, 
excepting  in  cases  of  very  great  violence,  open  the  shoulder- 
joint,  for  the  capsule  is  firmly  attached  to  the  epiphysis  and  the 
synovial  membrane  is  loosely  attached  to  the  diaphysis  (see  Fig. 
569).  In  the  adult  the  epiphyseal  line  marks  the  upper  limit  of 
the  surgical  neck. 

The  lower  epiphysis  of  the  femur,  the  largest  epiphysis  in 
the  body,  appears  before  birth,  attains  a  good  size  by  two  years, 


406 


ANATOMICAL    FACTS    REGARDING    THE    EPIPHYSES 


and  unites  to  the  cliaphysis  at  from  the  twentieth  to  the  twenty- 
third  year.     (For  Separation  of  this  Epiphysis  see  p.  309.) 

The  adductor  tubercle  is  on  the  diaphysis  marking  the  level 
of  the  line  of  the  epiphysis  upon  the  inner  side  of  the  femur. 
The  two  heads  of  the  gastrocnemius  muscle  are  attached  to  both 
the  epiphysis  and  the  diaphysis,  but  chiefly  to  the  diaphysis. 
The  plantaris  is  attached  to  the  diaphysis.  Both  of  these  mus- 
cles, in  a  separation  of  the  epiphysis,  are  stripped  from  the  shaft 
with  the  periosteum,  and  act  solely  on  the  detached  epiphysis, 
causing  it  to  rotate  upon  its  transverse  axis.    In  separations  with- 


Fig.  573-  —  Relations  of  the  synovial 
membrane  of  the  wrist-joint  to  the  epiphy- 
ses of  the  radius  and  ulna.  Note  also  the 
inferior  radio-ulnarjointand  synovial  mem- 
brane (diagram). 


Fig.  574. — Diagram  of  the  epiphyses  ai 
the  elbow,  about  the  fourteenth  year:  a, 
Shaft  of  humerus;  b,  capitellum  ;  c,  head 
of  radius;  li,  internal  condyle;  e,  tro- 
chlear;/", external  epicondyle. 


out  much  displacement  the  knee-joint  is  not  opened.  The  quad- 
riceps bursa  may  escape  injury  (see  Figs.  570,  571). 

The  lower  epiphysis  of  the  radius  appears  about  the  second 
year,  and  unites  to  the  shaft  at  from  the  nineteenth  to  the  twen- 
tieth year.     (For  Separation  of  this  Epiphysis  see  p.  229.) 

The  synovial  membrane  of  the  wrist-joint  does  not  touch  the 
epiphyseal  line  of  the  radius  either  anteriorly  or  posteriorly.  It 
takes  its  origin  from  the  lower  articular  margin  of  the  epiphysis. 
The  synovia]  membrane  of  the  inferior  radio-ulnar  articulation 
extends  above  the  epiphyseal  lines  of  both  the  radius  and  ulna. 
It   is    loosely  connected    with    the   diaphysis   of  each    bone.      In 


THE    LOWER    EPIPHYSIS    OF    THE    HUMERUS 


407 


epiphyseal  separations  laceration  of  the  synovial  pouch  is  possi- 
ble, but  is  not  absolutely  inevitable  (see  Figs.  572,  573). 

The  lower  epiphysis  of  the  humerus  is  formed  from  three 
separate  centers  of  ossification — viz.,  the  capitellum,  which 
appears  at  three  years  ;  the  trochlea,  which  appears  at  eleven 
years  ;  the  external  epicondyle,  which  appears  at  thirteen  years 
(see  Fig.  574).  These  three  centers  coalesce  at  about  the  fif- 
teenth year,  to  form  the  lower  humeral  epiphysis.      The  epiphy- 


Fig.  575. — Tibia  showing  epiphyses  (Warren 
Museum,  specimen  417). 


Fig.  576. — Fibula,  showing  epiphyses 
(Warren  Museum  specimen). 


sis  unites  to  the  diaphysis  at  about  the  seventeenth  year.  The 
epiphysis  for  the  internal  epicondyle  forms  no  part  of  the  lower 
humeral  epiphysis.  It  appears  at  about  the  fifth  year,  and  joins 
the  diaphysis  at  from  the  eighteenth  to  the  twentieth  year.  (For 
Separation  of  this  Epiphysis  see  p.  I J  I.) 

The  synovial  membrane  at  about  the  fifteenth  year  and  after- 
ward overlaps  the  epiphyseal  line.  The  epiphyseal  line  is  a  little 
higher  on  the  outer  side  than  on  the  inner.      It  inclines  obliquely 


4oS 


ANATOMICAL    FACTS    REGARDING    THE    EPIPHYSES 


downward  and  inward.  The  epiphysis  is  thinner  internally  than 
externally. 

The  epiphysis  of  the  lower  end  of  the  tibia  appears  about 
the  second  year,  and  unites  to  the  diaphysis  about  the  eighteenth 
or  nineteenth  year.  Neither  anteriorly  nor  posteriorly  does  the 
synovial  membrane  come  in  contact  with  the  epiphyseal  line,  so 
that,  unless  great  violence  is  exercised  or  the  epiphysis  is  frac- 
tured, the  ankle-joint  is  unopened  in  separation  of  this  epiphysis 
(see  Figs.  575,  576). 

The  epiphysis  of  the  upper  end  of  the  tibia  (see  Fig.  575) 


Fi.K-  577- — Right  scapula  from  above  and  behind  :  Fig.  578. — Relation  of  the  cap- 

a,  Epiphysis  of  acromion;    b,  epiphysis  of  coracoid  sule  of  the  hip-joint   to  the   upper 

process;   c,  epiphysis  of  glenoid  cavity  (from   speci-  epiphysis  of  the  femur, 
mens  in  Warren  Museum). 


appears  at  about  the  first  year,  and  unites  to  the  shaft  at  the 
twentieth  or  twenty-second  year.  The  synovial  membrane  is 
quite  a  little  distance  from  the  line  of  the  epiphysis.  The  epiph- 
yseal line  runs  quite  close  to  the  superior  tibiofibular  articulation. 
The  acromion  process  of  the  scapula  (see  Fig.  577)  presents 
an  epiphysis  that  appears  at  from  the  fourteenth  to  the  six- 
teenth year,  and  unites  at  from  the  twenty-second  to  the  twenty- 
fifth  year.  The  epiphysis  includes  the  oval  articular  facet  for  the 
clavicle.  The  coracohumeral  and  acromioclavicular  ligaments 
are  attached  to  it.  The  epiphysis  joins  the  acromion  behind 
the  acromioclavicular  joint. 


CHAPTER  XVII 

THE  RONTGEN  RAY  AND  ITS  RELATION  TO 
FRACTURES 

BY  E.  A.  CODMAN,  M.D. 

On  January  23,  1896,  Rontgen  read  his  announcement  of  the 
discovery  of  the  X-rays  before  the  Physico-medical  Society  at 
Wurzburg.      The  extraordinary  news  fled  over  the  world  in  an 
incredibly  short  time.      Within  a  few  months  skiagraphs  of  the 
bones  of   the   hands   appeared   in   every  newspaper   that    could 
afford  an   illustration,  and  the  reporters  indulged  their  imagina- 
tions  and   dwelt   on   the   advantages  the    new   discovery  would 
bring  to  medicine  and  surgery.      The  strangeness  of  the  subject 
offered    an    unusually    brilliant    field    for    the    imaginative    and 
humorous,   and   in   consequence  it  will    undoubtedly   be    years 
before  the  public  is  disabused  of  its  first  erroneous  impressions. 
Perhaps   more   people   err   now  on   the   side   of  incredulity  than 
credulity,  and  are  inclined  to  regard  the  wonders  they  heard  of 
at  first  as  "  newspaper  talk."     Medical  men  are  particularly  sub- 
ject to  this  criticism,  and   there   are   many  who   seem  to   feel   a 
disappointment  in  the  results.      It  is  unfortunate  that  Rontgen's 
original  article  was  not  widely  published  in  the  first  place,  for  it  is 
a  model  of  scientific  accuracy,  and  contains  not  a  single  statement 
that  has  not  been  substantiated  again  and  again.      To  those  men 
who   understood  the   limitations   of  the   X-ray  that  this  article 
pointed  out,  the  results  have  not  been  disappointing.      On  the 
contrary,    the    improvements    in    apparatus    and    technic    have 
enlarged  the  scope  of  its   use  and   increased  the  importance   of 
the  information  it  gives  us.      The  X-ray  department  has  become 
a  necessity  in  every  large  general  hospital. 

In  discussing  the  value  of  Rontgen's  discovery  in  a  book  on 
the  treatment  of  fractures  it  has  seemed  wise  to  point  out  some 
of  the  mistakes  that  are  commonly  made  in  the  interpretation  of 

409 


4-IO      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

skiagraphs.  To  those  who  have  done  practical  work  with  the 
X-rays  this  chapter  will  be  valueless  ;  but  those  who  have  not 
may  find  in  it  some  assistance  in  their  effort  to  learn  what  real 
value  the  new  science  is  to  this  branch  of  surgery. 

Among  other  misconceptions  the  Crooke's  tube  was  supposed 
to  emit  a  very  powerful  light.  It  is  not  a  powerful  light,  but 
merely  a  faint  one  of  such  quality  that  it  is  able  to  penetrate 
substances  that  ordinary  light  does  not.  It  is  its  peculiar 
quality,  not  its  intensity,  that  enables  it  to  penetrate  opaque  ob- 
jects. It  is  invisible  to  our  eyes,  but  has  the  quality  of  causing 
chemical  action  on  a  photographic  plate  or  of  affecting  crystals 
of  certain  substances  so  as  to  make  them  emit  a  faint  light.  A 
sort  of  sand-paper  made  of  these  crystals,  finely  ground,  forms  a 
fluorescent  screen,  or  fluoroscope  ;  and  any  substance  that  is 
not  easily  penetrated  by  these  rays,  when  placed  between  the 
source  of  light  and  the  screen,  will  cut  off  the  rays  and  cast  a 
shadow  on  the  sand-paper  that  can  be  seen  on  the  side  away 
from  the  object.  This  shadow  will  be  more  or  less  deep,  accord- 
ing to  whether  the  substance  cuts  off  more  or  less  rays.  Thus, 
iron  casts  a  darker  shadow  than  wood  ;  bone,  a  darker  shadow 
than  flesh.  In  general  the  opacity  of  different  substances  varies 
directly  with  their  atomic  weights.  In  the  same  way  the  sub- 
stance placed  between  the  source  of  light  and  a  photographic 
plate  will  cut  off  some  of  the  rays  from  the  plate.  Where  these 
are  cut  off,  chemical  action  does  not  occur  ;  where  some  of  the 
rays  go  through,  it  occurs  slightly  ;  where  the  object  does  not 
interfere  at  all  and  the  rays  strike  the  plate  directly,  the  action 
is  greatest.  When  the  plate  is  developed,  we  get  a  picture  of 
the  shadow  of  the  object  with  its  most  dense  parts  most  deeply 
shaded. 

Many  people  confuse  an  X-ray  picture  with  a  photograph. 
They  take  it  to  be  a  photograph  by  X-ray  light.  It  is  not  a 
photograph,  but  a  shadow-picture,  a  compound  silhouette,  a  pro- 
jection of  the  parts  of  an  object.  A  photograph  of  the  hand  is 
made  by  the  light  reflected  from  the  hand  to  the  photographic 
plate,  and  shows  the  surface  of  the  skin.  A  skiagraph  of  the 
hand  is  made  by  the  light  that  has  passed  through  the  hand, 
and  shows  a  chart  of  the  different  densities  of  the  different  con- 


MISTAKES    IN    INTERPRETATION    OF    SKIAGRAPHS  41  I 

stituents  of  the  hand,  as  bone,  muscle,  fat,  and  skin.  As  the 
other  parts  of  the  hand  are  of  about  equal  density  and  this  den- 
sity is  much  less  than  that  of  bone,  the  bones  appear  promi- 
nently on  the  chart.  The  thickest  portions  and  most  dense 
portions  of  the  bone  appear  more  deeply  marked  than  the  lighter 
and  spongy  portions.  As  every  little  gradation  of  density  is 
registered,  the  whole  forms  a  picture. 

As  far  as  we  know,  the  effects  of  the  X-rays  are  only  obtain- 
able in  the  immediate  neighborhood  of  their  source  ;  that  is,  a 
small  point  on  the  platinum  reflector  in  the  Crooke's  tube.  From 
this  point  they  radiate  in  all  directions,  their  power  gradually 
diminishing  until  at  a  distance  of  about  a  hundred  feet  or  a  little 
more  they  are  not  appreciable  by  any  means  now  at  our  com- 
mand. Practically,  they  are  only  strong  enough  for  skiagraphic 
purposes  within  a  few  feet  of  the  tube. 

Since  they  proceed  from  a  point,  and  are  not  approximately 
parallel  like  the  sun's  rays,  their  shadows  are  necessarily  dis- 
torted. We  are  all  familiar  with  the  distorted  shadows  thrown 
on  the  wall  by  a  candle.  The  same  distortion  takes  place  in  an 
X-ray  picture  in  a  lesser  degree.  Since  the  rays  proceed  from  a 
point,  all  parts  of  an  object  can  not  stand  in  the  same  relation  to 
that  point  and  the  surface  of  a  plate  at  the  same  time.  The 
least  distortion  will  take  place  when  the  object  is  in  contact  with 
the  plate,  and  as  far  from  the  light  as  is  consistent  with  obtaining 
sufficient  effect  to  take  the  picture  :  that  is,  to  have  the  rays 
penetrate  the  less  dense  portions  of  the  object.  Let  the  dis- 
tance from  the  point  to  the  plate  remain  the  same.  It  follows 
that: 

(a)  Shadows  will  be  enlarged  in  proportion  to  the  distance  of 
the  object  from  the  plate,  toward  the  light. 

(/;)  Shadows  are  distorted  of  any  object  or  part  of  an  object 
not  in  a  perpendicular  line  from  the  point  of  light  to  the  surface 
of  the  plate,  and  that  distortion  takes  place  in  a  line  drawn  from 
the  base  of  such  perpendicular  through  that  object  or  part  of 
an  object. 

As  an  illustration  of  these  distortions,  we  have  represented  in 
figure  579  the  projection  of  a  cubical  block  of  wood  (a).      For 


412      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

convenience  of  drawing,  the  shadow  (£)  is  represented  at  an 
angle.  The  outside  square  of  b  represents  the  upper  surface  of 
the  block,  while  the  inner  square  represents  the  lower.  The 
density  of  the  shadow  is  greatest  at  the  edges  of  the  lower 
square,  for  they  represent  the  longest  paths  of  the  rays  through 
the  block.  From  the  consideration  of  figures  580,  581,  582, 
and  583  the  reader  will  readily  observe  that  any  change  in  the 


T<Jbr-. 


Fig.  579' 


tilt  of  the  plane  of  the  plate  (Fig.  581,  a)  in  the  shape  or  density 
of  the  object,  or  in  the  distance  of  the  point  of  light  (Fig.  582), 
will  produce  a  definite  alteration  of  the  shadow  or  picture.  It 
is,  therefore,  necessary  in  looking  at  a  skiagraph  to  know  how 
tlw  plane  of  the  plate  lay,  how  far  distant  the  light  was,  and,  in 
general,  what  the  shape  and  density  of  the  different  parts  of  the 
1  ibject  were. 


THE  INTERPRETATION  OF  SKIAGRAPHS 


413 


Just  as  it  is  true  that  the  shadow  of  any  object  increases   in 
size  as  it  is  moved  from  the  plate  toward  the  light,  so  also  it 


Fig.  580. 


Plal 


Ttate 


k_  Plate 


Plate 


Fig.  581. 


is  true  that  the  density  of  the  shadow  decreases  as  its  size  in- 
creases. Each  object  that  is  translucent  to  the  X-rays  seems 
to  have  the  ability  to  cut  off  a  certain  amount  of  X-ray  light. 


414      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

In  other  words,  it  contains  a  certain  amount  of  shadow-casting 
material.  As  it  is  moved  from  the  plate  toward  the  light  its 
shadow  increases  in  size,  but  diminishes  in  density,  since  only  a 
certain  amount  of  light  can  be  obstructed  by  that  object. 

Putting  it  in  another  way,  we  see  that  the  object  x  y  (Fig. 
580)  in  the  angle  a  b  c  interferes  with  three  times  as  much 
light  as  if  in  the  position  of  a  d  e,  but  since  it  can  only  cut  off 
a  certain  quantity  of  rays  in  either  position,  the  shadow  in  d  e 
will  be  darker,    though    smaller  than    b  c.      Of   course,   if  x  y 


Fig.  582. 


Fig-  5«3- 


were  not  penetrated  at  all  by  the  rays,  the  shadow  would  be  at 
a  maximum  in  both  cases.  In  a  b  c  there  are  three  times  as 
many  rays  to  go  through,  but  x  y  can  only  subtract  a  certain 
number.  It  can  subtract  that  number  from  a  d  e  where  there 
will  be  a  smaller  remainder  and  hence  a  deeper  shadow.  This 
is  an  especially  important  point  to  keep  in  mind,  for  the  range  of 
variation  of  density  of  different  bones  is  very  small,  and  a  very 
slight  change  in  position  in  relation  to  the  plate  may  make  an 
enormous  difference  in  the  resulting  picture.  For  example,  figure 
5S4,  a  skiagraph  of  the  knee  taken  from  behind, — i.  c,  with   the 


THE  INTERPRETATION  OF  SKIAGRAPHS 


415 


plate  behind, — C  shows  little  or  no  sign  of  the  patella.  While 
with  the  plate  in  front  (B)  and  the  tube  behind,  the  outline  of  the 
patella  is  distinguishable  through  the  shadow  of  the  femur. 
This  is  the  more  decided  if  the  tube  is  brought  quite  near  to  the 
back  of  the  knee  (A),  for  then  the  size  of  the  shadow  of  the 
femur  is  increased  and  its  density  diminished,  while  that  of  the 
patella  remains  nearly  the  same  in  both  size  and  density. 

Another  point  that,  though  simple,  seems  to  cause  misunder- 
standing is  illustrated  in  figure  583,  representing  the  shadow  of 
a  section  of  one  of  the  cylindrical  bones.      It  is  intended  to  show 


TUte 


PLa.tt 


why  a  long  bone  appears  like  a  longitudinal  section  in  a  skia- 
graph. Though  the  whole  circumference  may  be  of  the  same 
thickness,  the  rays  that  pass  through  the  sides,  x—v,  meet  more 
resistance  than  those  through  the  center  ;  hence  the  medullar)7 
cavity  appears  on  the  plate. 

It  is  often  of  great  assistance  to  plot  out  on  paper  a  projection 
of  the  salient  points  of  the  subject,  as  in  figure  579,  at  the  same 
time  bearing  in  mind  that  variations  occur  in  density  as  well  as 
in  size.  We  should  like  to  go  into  the  question  of  the  decep- 
tiveness  of  skiagraphs  at  greater  length,  because  we  regard  it 
as  of  the  utmost  importance  that  every  physician  who  uses  this 


4 1 6      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

means  of  diagnosis  should  fully  understand  the  way  in  which  any 
conclusion  should  be  drawn  from  one  of  these  pictures.  Though 
the  pictures  themselves  are  inaccurate  as  pictures  of  the  object, 
they  are  accurate  pictures  of  the  shadows  of  the  different  parts 
of  the  object,  and  the  reasoning  of  conclusions  drawn  from  them 
should  be  exact. 

In  answer  to  the  question  of  what  help  the  X-ray  has 
been  in  increasing  our  knowledge  of  the  pathology  and  treat- 
ment of  fractures,  we  may  mention  first  the  general  points 
and  then  the  particular  fractures  in  which  we  find  it  to  be  of 
benefit.  Although  surgeons  have  always  realized  very  nearly 
accurately  the  position  of  the  displaced  fragments  in  the  common 
fractures,  there  can  be  no  doubt  that  the  production  of  pictures  of 
the  exact  condition  in  individual  cases  gives  more  reliable  infor- 
mation of  the  condition  and  relation  of  the  broken  ends  than  can 
possibly  be  obtained  by  palpation.  A  more  definite  knowledge 
of  the  pathology  brings  greater  exactness  of  treatment.  When 
the  splints  are  applied,  it  can  be  ascertained  whether  the  position 
is  good  without  removing  the  bandages.  Little  details  that 
otherwise  would  escape  notice  are  brought  out.  The  patient  is 
spared  painful  manipulation  or  etherization  and  the  bruising  and 
laceration  of  the  tissues  from  unnecessary  handling.  The  ques- 
tion of  a  cutting  operation  to  reduce  otherwise  intractable  frag- 
ments may  be  decided  by  an  exact  knowledge  of  the  positions 
of  the  parts.  This  subject  of  the  advisability  of  interference  by 
making  a  simple  fracture  compound  is  one  that  is  attracting 
more  and  more  attention,  and  will  lead  to  its  being  made  the  rule 
in  cases  where  a  perfect  result  can  not  be  expected  by  the  simple 
method.  When  asepsis  can  be  practised,  there  is  little  danger  of 
making  an  incision,  and  the  time  saved  in  cases  where  approxi- 
mation of  the  fragments  is  prevented  by  loose  bits  of  bone  or  soft 
parts  is  well  worth  this  slight  risk. 

At  present  we  find  the  X-rays  of  more  assistance  in  the 
stud\'  of  the  pathology  of  fractures  than  we  do  in  their  treat- 
ment. For  though  we  believe  that  in  each  individual  case  of 
fracture  a  skiagraph  is  of  decided  assistance,  yet  it  must  be  con- 
fessed that  the  cases  where  it  leads  us  to  modify  the  treatment 
to  any  considerable  extent  arc  few  in   number.       A  diagnosis 


ITS    PRACTICAL    VALUE  417 

of  fracture  without  skiagraphs  is  always  open  to  doubt,  while 
with  a  careful  X-ray  examination  there  is  seldom  a  doubt.  We 
appreciate  the  X-ray,  too,  when,  after  applying  our  splints, 
even  if  plaster,  we  assure  ourselves  of  the  correct  alinement  of 
the  bones. 

As  a  means  of  demonstrating  to  students  the  pathology  of 
fractures,  a  series  of  lantern-slides  is  of  the  greatest  assistance. 
The  knowledge  that  the  pictures  are  of  actual  cases  and  not 
theoretic  diagrams  gives  a  practical  interest  that  is  akin  to  clin- 
ical instruction.  The  plates  when  shown  at  the  same  time  as  the 
case  at  a  hospital  clinic  also  serve  to  illustrate  the  pathology  and 
indications  for  treatment. 

A  not  unimportant  result  of  the  use  of  Rontgen's  discovery  is 
the  exactness  it  offers  as  a  method  of  record  in  the  rarer  frac- 
tures. Heretofore  statistics  on  the  uncommon  forms  of  fracture 
have  always  been  open  to  the  doubt  of  mistaken  diagnoses,  and 
we  have  been  dependent  on  the  chance  of  securing  postmor- 
tem specimens  in  order  to  obtain  accuracy.  In  future  the 
recorded  cases  of  this  kind  can  be  illustrated  by  skiagraphs, 
and  we  may  look  forward  to  not  only  greater  accuracy,  but  to  a 
much  greater  number  of  cases  that  were  formerly  considered 
rare.  Every  large  hospital  will  be  able  to  turn  to  its  records 
and  say  definitely  in  what  percentage  any  given  fracture  occurred. 
At  the  same  time,  each  individual  case  has  the  benefit  of  a 
definite  record,  and  the  result  can  be  compared  with  the  extent 
of  injury. 

The  reader  will  now  ask  in  what  forms  of  fracture  can  we 
say  the  X-ray  is  of  great  assistance.  In  general,  those  bones 
that  can  be  brought  near  the  plate  or  that  are  not  over- 
shadowed by  other  bones  give  the  most  satisfactory  skiagraphs. 
Therefore,  little  can  be  expected  of  skiagraphs  of  the  bones  of 
the  head  or  vertebrae,  while  those  of  the  extremities  come  out 
with  great  precision.  The  pelvic  and  shoulder-bones  stand 
midway  between  these,  but  with  a  good  apparatus  and  care  in 
the  choice  of  the  relative  positions  of  the  plate,  tube,  and  the 
particular  portion  of  the  bone  to  be  taken,  we  may  expect  a  def- 
inite picture.  Even  in  the  case  of  the  skull  and  vertebrae  we 
occasionally  find  a  skiagraph  of  advantage.  The  entire  contour 
27 


41 8      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

of  the  lower  jaw  can  be  easily  investigated  ;  the  nasal,  alveolar, 
and  mastoid  processes  and  malar  bones  come  out  sharply  ;  the 
cervical  vertebrae,  both  from  behind  and  from  the  side,  can  be 
brought  out  with  great  detail,  while  the  dorsal  and  lumbar, 
though  not  appearing  clearly,  sometimes  show  the  rough  out- 
lines of  bodies  and  articular,  transverse,  and  spinous  processes. 
Any  particular  portion  of  any  particular  rib,  except  the  necks,  can 
be  taken  with  great  accuracy,  since  the  plate  can  be  laid  almost 
directly  upon  it.  The  clavicle,  too,  comes  out  clearly.  The 
sternum  is  too  much  overshadowed  by  the  dense  dorsal  vertebrae 
to  show  definite  outlines. 

Fractures  in  the  shoulder-joint  are  often  impossible  to  recog- 
nize without  the  X-ray,  particularly  in  those  cases  where  the 
swelling  and  effusion  about  the  joint  prevent  manipulation.  Frac- 
tures of  the  tuberosities  of  the  humerus,  of  the  surgical  and  ana- 
tomical necks,  can  be  differentiated  with  great  certainty.  When 
separation  and  dislocation  of  the  epiphysis  have  occurred,  we  may 
decide  the  question  of  operation  ;  and  the  same  question  may  be 
answered  in  those  puzzling  cases  in  which  fracture  of  the  neck  has 
occurred  with  dislocation.  Separation  of  the  tuberosities  we  now 
find  is  a  much  more  common  accident  than  we  had  supposed. 
Even  in  breaks  of  the  shaft  of  the  humerus  and  the  other  long 
bones  we  gain  much  information.  The  extent,  direction,  and 
plane  of  cleavage,  with  the  exact  amount  of  displacement,  are 
guides  for  the  application  of  padding  and  splints.  It  is  in  frac- 
tures of  the  long  bones  particularly  that  a  second  series  of  skia- 
graphs with  the  splints  in  position  is  of  value.  The  amount 
of  shortening  is  shown  more  accurately  than  by  measuring  the 
landmarks,  for  the  overlapping  can  be  distinctly  seen.  If  neces- 
sary, the  approximation  of  the  fragments  can  be  aided  by  proper 
pads. 

It  is  not  out  of  place  here  to  refer  again  to  the  question  of 
distortion,  for  in  these  cases  one  must  remember  that  not  only 
may  the  bones  be  magnified,  but  also  the  interspace  between 
them.  Two  or  more  pictures  must  be  taken,  for  a  view  from  the 
side  will  often  show  a  displacement  that  is  not  brought  out  in 
the  shadow  from  in  front  or  behind.  The  fluoroscope  is  particu- 
larly useful  in  this  sort  of  work,  for,  while  it  does  not  give  the 


ITS    PRACTICAL    VALUE  4  I  9 

detail  that  can  be  seen  in  a  plate,  it  is  clear  enough  to  assure 
one  of  the  alinement  of  the  parts  and  avoids  the  trouble  of  tak- 
ing and  developing  the  plates.  In  general  work,  however,  we 
place  less  reliance  on  the  fluoroscope  and  rely  on  the  skiagraph. 
As  will  be  pointed  out  later,  the  use  of  the  fluoroscope,  also,  is 
not  without  danger  of  dermatitis. 

It  is  in  injuries  about  the  elbow-joint  that  we  must  be  more 
than  ever  upon  our  guard  to  avoid  false  conclusions  from  the 
distortions  that  we  have  endeavored  to  point  out.  It  will  be 
most  useful  to  any  practitioner  who  intends  to  do  X-ray  work  to 
take  a  series  of  skiagraphs  of  the  normal  elbow-joint  from  dif- 
ferent positions  and  in  different  positions,  and  to  study  most 
carefully  the  projections  of  the  parts  in  each.  Such  a  series  of 
injuries  occur  in  this  region  that  the  diagnoses  are  most  difficult, 
and  the  skiagraph  correctly  interpreted  is  of  the  greatest  help. 
Cases  that  formerly  appeared  in  hospital  records  as  "  injury  to 
elbow"  are  now  divided  into  "fractures  of  head  of  radius," 
"  neck  of  radius,"  "  separation  of  coronoid  process,"  etc.  A 
feature  which  is  now  thoroughly  brought  out  is  the  common 
occurrence  of  fracture  with  dislocation.  Injuries  to  the  elbow 
are  particularly  puzzling  in  children,  since  the  ossification  of  the 
epiphyses  is  found  in  different  stages,  and  the  cartilaginous  por- 
tions do  not  show  in  our  plates.  We  may  expect  better  results 
in  this  field  when,  by  study  and  experience,  we  learn  more  of  the 
time  and  mode  of  formation  of  the  epiphyses. 

In  the  wrist  Rontgen's  discovery  has  taught  us  much.  We 
find  in  the  fracture  of  the  lower  end  of  the  radius  a  variety  of 
types.  Breaking  of  the  styloid  of  the  ulna  is  found  to  exist 
much  more  often  than  was  supposed.  The  styloid  of  the  ulna 
was  fractured  in  80  per  cent,  of  140  cases  of  Colles'  fracture. 
Fracture  of  the  scaphoid  is  also  not  uncommon  both  alone  and 
in  conjunction  with  Colles'  fracture.  Fractures  of  the  semilunar 
and  os  magnum  are  also  reported.  The  metacarpals  and  phal- 
anges offer  a  less  interesting  field,  but  in  the  former,  when  impac- 
tion into  the  distal  extremity  has  occurred  and  it  is  impossible 
to  obtain  crepitus  or  mobility,  a  skiagraph  shows  clearly  the 
condition. 

Improvements  in  apparatus  and  technique  have  enabled  us  to 


420      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

get,  as  a  rule,  clear  pictures  of  the  upper  extremity  of  the  femur 
when  normal  or  recently  broken.  When  diseased  or  sur- 
rounded by  much  inflammatory  thickening  or  calcareous  deposit, 
the  outlines  are  blurred  and  unsatisfactory,  but  yet  throw  light 
on  the  diagnosis.  There  are  often  puzzling  cases  when  fracture, 
dislocation,  tuberculosis,  and  coxa  vara  all  have  to  be  considered, 
and  in  which  a  skiagraph  is  of  the  greatest  assistance.  Any 
portion  of  the  shaft  of  the  femur  can  be  taken,  and,  since  portable 
X-ray  apparatus  have  come  into  use,  the  picture  maybe  obtained 
without  disturbing  the  patient  or  his  dressings.  Of  the  knee 
we  get  very  clear  plates.  Of  the  method  of  taking  the  patella 
we  have  already  spoken.  We  can  compare  the  results  of  the 
traction  treatment  with  those  of  suture  and  wiring.  It  is  of 
assistance  in  determining  whether  the  fragments  are  not  too 
much  shattered  to  admit  of  wiring. 

In  injuries  of  the  lower  leg  we  may  apply  what  has  already 
been  said  of  the  other  long  bones,  and  in  addition  mention  a 
case  in  which  a  fragment  from  the  external  malleolus  lodged  back 
of  the  astragalus  under  the  tendo  Achillis.  In  the  foot,  as  in  the 
wrist,  the  X-ray  has  taught  us  much.  Numerous  cases  of  breaks 
in  the  os  calcis,  astragalus,  and  scaphoid  have  been  reported, 
and,  though  fractures  of  the  other  tarsal  bones  have  not  fallen 
within  our  experience,  their  occurrence  might  easily  be  recog- 
nized. Gocht  points  out  that  many  swollen  feet  of  uncertain 
diagnosis  prove  to  be  fractures  of  the  metatarsals.  He  also 
reports  fracture  of  one  of  the  sesamoid  bones  of  the  great 
toe. 

It  is  commonly  said  that  the  X-ray  is  dangerous  to  the  patient 
and  burns  the  skin  and  destroys  the  hair.  This  is  true  as  a 
possibility,  but  nowadays  is  only  to  be  feared  in  connection  with 
gross  ignorance  and  carelessness.  It  is  a  fact  that  Crooke's  tube 
in  action  is  capable  of  causing  an  effect  on  the  tissues  similar  in 
many  respects  to  a  burn.  But  this  action  does  not  take  place 
unless  the  tissues  are  exposed  to  the  tube  for  a  considerable 
period  of  time  and  at  a  very  short  distance  :  For  instance,  eight 
inches  from  the  tube  for  an  exposure  of  five  minutes  we  should 
consider  perfectly  safe  ;  one  inch  from  the  tube  and  five  minutes, 
dangerous.       Probably    the    skins    of  different    people    vary  in 


THE    LOCAL    EFFECT    OF    THE    RONTGEN    KAY  42  I 

susceptibility  to  this  influence,  but  we  doubt  if  injury  ever 
occurred  unless  the  tube  was  within  a  foot  of  the  patient. 

Danger  to  the  hands  of  the  operator  of  the  apparatus  is  quite 
another  matter,  for  repeated  exposure  may  produce  the  same 
condition.  The  most  severe  cases  occur  when,  in  the  use  of  the 
fluoroscope,  the  operator  puts  his  hand  near  the  tube,  either  to 
hold  the  patient's  limb  in  place  or  to  demonstrate  the  bones  of 
his  hand  to  an  audience.  Physicians  who  are  called  upon  to 
use  the  fluoroscope  often  should  wear  rubber  gloves  to  protect 
the  hands,  or  cover  the  tube  with  a  grounded  aluminium  screen. 
Most  of  the  recorded  cases  of  severe  injury  took  place  when  the 
new  light  was  first  used,  and  experience  had  not  pointed  out 
these  cautions.  To-day,  with  our  improved  apparatus,  the 
penetration  and  definition  render  a  closer  approach  to  the  tube 
than  twelve  inches  unnecessary.  The  cause  of  these  burns  has 
been  a  subject  of  much  discussion,  and  it  may  still  be  considered 
an  open  question.  There  are  many  who  believe  it  to  be  due  to 
an  electrostatic  effect,  while  others,  among  whom  is  Professor 
Elihu  Thomson,  affirm  that  the  Rontgen  rays  themselves  are 
responsible.  Professor  Thomson  certainly  should  be  an  au- 
thority on  this  point,  for  he  has  not  only  the  advantages  of 
his  electrical  knowledge,  but  also  of  experimental*  experience. 
The  following  is  a  quotation  from  a  personal  letter  from  him  in 
November,  1896,  describing  a  somewhat  heroic  experiment. 

"  Hearing  of  the  effects  of  the  X-rays  on  the  tissues,  especially 
on  the  skin,  I  determined  to  find  out  what  foundation  the  state- 
ments had  by  exposing  a  single  finger  to  the  rays.  I  used  for 
this  the  little  finger  of  the  left  hand,  exposing  it  close  up  to  the 
tube,  about  one  and  one-quarter  inches  from  the  platinum 
source  of  the  rays,  for  one-half  an  hour.  For  about  nine  days 
very  little  effect  was  noticed  ;  then  the  finger  became  hyper- 
sensitive to  the  touch,  dark  red,  somewhat  swollen,  stiff;  and 
soon  after,  the  finger  began  to  blister.  The  blister  started  at 
the  maximum  point  of  action  of  the  rays,  spread  in  all  directions 
covering  the  area  exposed,  so  that  now  the  epidermis  is  nearly 
detached  from  the  skin  ;  underneath  and  between  the  two  there 
is  a  formation  of  purulent  matter  that  escapes  through  a  crack 
in  the  blister.      It  will  be  three  weeks  to-day  since  the  exposure 


42  2      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

was  made,  and  the  healing  process  seems  to  be  as  slow  as  the 
original  coming  on  of  the  trouble." 

Four  days  later  :  "  The  whole  epidermis  is  off  the  back  of  the 
finger  and  off  the  sides  of  it  also,  while  the  tissue  even  under  the 
nail  is  whitened  and  probably  dead,  ready  to  be  cast  off.  The 
back  of  the  finger  for  a  considerable  extent,  where  it  received 
the  strongest  radiation,  is  raw  and  will  not  recover  its  epidermis, 
apparently,  except  from  the  sides  of  the  wound." 

Not  entirely  satisfied  with  this  experiment,  Professor  Thom- 
son shortly  afterward  repeated  it  on  another  finger,  which  he 
covered  with  some  aluminium  foil  in  such  a  way  as  to  convince 
him  that  the  tissue,  while  still  exposed  to  the  X-ray,  was 
shielded  from  the  brush  discharge.  As  he  obtained  the  same 
result,  he  concluded  in  favor  of  the  Rontgen  ray  itself.  In  a 
recent  article  on  the  subject  he  shows  that  this  effect  is  due  to 
those  of  the  rays  that  are  less  readily  transmitted  by  the  tissues 
and  are  less  valuable  for  skiagraphic  purposes. 

This  quotation  is  made  not  only  from  its  value  as  an  experi- 
ment, but  also  because  it  is  so  clear  a  description  of  this  form 
of  dermatitis.  The  long  period  before  the  effects  became  evident 
is  quite  characteristic,  although  in  many  cases  they  have  ap- 
peared sooner.  It  seems  probable  that  the  direct  effect  is  on 
the  vasomotor  or  trophic  nerve  supply,  which  eventually  affects 
the  nutrition  of  the  part. 

This  chapter  has  been  mainly  devoted  to  warnings  of  the 
dangers  of  the  Rontgen  ray,  and  may  in  a  measure  discourage 
practitioners  from  its  use.  It  should  be  stated,  however,  that 
when  the  limits  of  error  are  kept  clearly  in  mind,  the  actual 
value  of  the  discovery  to  surgical  science  is  very  great.  When 
there  is  doubt  of  the  detailed  diagnosis  of  a  fracture,  no  physi- 
cian has  done  his  full  duty  by  his  patient  if  he  can  command 
skiagraphic  examination  and  has  not  used  it.  This  is  particu- 
larly true  in  medicolegal  cases  where  there  is  a  question  of 
liability. 


medicolegal  relations  of  x-rays  423 

Conclusions  Expressing  the  Views  of  The  American  Sur- 
gical Association  upon  the  Medicolegal  Relations  of 
X-rays;  Adopted  in  May,    1900. 

1.  The  routine  employment  of  the  X-ray  in  cases  of  fracture 
is  not  at  present  (1900)  of  sufficient  definite  advantage  to  justify 
the  teaching  that  it  should  be  used  in  every  case.  If  the  sur- 
geon is  in  doubt  as  to  his  diagnosis,  he  should  make  use  of  this 
as  of  every  other  available  means  to  add  to  his  knowledge  of  the 
case,  but  even  then  he  should  not  forget  the  grave  possibilities  of 
misinterpretation.  There  is  evidence  that  in  competent  hands 
plates  may  be  made  that  will  fail  to  reveal  the  presence  of  exist- 
ing fractures  or  will  appear  to  show  a  fracture  that  does  not 
exist. 

2.  In  the  regions  of  the  base  of  the  skull,  the  spine,  the  pelvis, 
and  the  hips,  the  X-ray  results  have  not  as  yet  been  thoroughly 
satisfactory,  although  good  skiagraphs  have  been  made  of  lesions 
in  the  last  three  localities.  On  account  of  the  rarity  of  such 
skiagraphs  of  these  parts,  special  caution  should  be  observed, 
when  they  are  affected,  in  basing  upon  X-ray  testimony  any 
important  diagnosis  or  line  of  treatment. 

3.  As  to  questions  of  deformity,  skiagraphs  alone,  without 
expert  surgical  interpretation,  are  generally  useless  and  frequently 
misleading.  The  appearance  of  deformity  may  be  produced  in 
any  normal  bone,  and  existing  deformity  may  be  grossly  exag- 
gerated. 

4.  It  is  not  possible  to  distinguish  after  recent  fractures 
between  cases  in  which  perfectly  satisfactory  callus  has  formed 
and  cases  which  will  go  on  to  nonunion.  Neither  can  fibrous 
union  be  distinguished  from  union  by  callus  in  which  lime-salts 
have  not  yet  been  deposited.  There  is  abundant  evidence  to 
show  that  the  use  of  the  X-ray  in  these  cases  should  be  regarded 
as  merely  the  adjunct  to  other  surgical  methods,  and  that  its 
testimony  is  especially  fallible. 

5.  The  evidence  as  to  X-ray  burns  seems  to  show  that  in  the 
majority  of  cases  they  are  easily  and  certainly  preventable.  The 
essential  cause  is  still  a  matter  of  dispute.  It  seems  not  unlikely, 
when  the  strange  susceptibilities  due  to  idiosyncrasy  are  remem- 


424      THE    RONTGEN    RAY    AND    ITS    RELATION    TO    FRACTURES 

bered,  that  in  a  small  number  of  cases  it  may  make  a  given 
individual  especially  liable  to  this  form  of  injury. 

6.  In  the  recognition  of  foreign  bodies  the  skiagraph  is  of  the 
very  greatest  value  ;  in  their  localization  it  has  occasionally 
failed.  The  mistakes  recorded  in  the  former  case  should  easily 
have  been  avoided  ;  in  the  latter,  they  are  becoming  less  and  less 
frequent,  and  by  the  employment  of  accurate  mathematical 
methods  can  probably  in  time  be  eliminated.  In  the  mean  while, 
however,  the  surgeon  who  bases  an  important  operation  on  the 
localization  of  a  foreign  body  buried  in  the  tissues  should  remem- 
ber the  possibility  of  error  that  still  exists. 

y.  It  has  not  seemed  worth  while  to  attempt  a  review  of  the 
situation  from  the  strictly  legal  standpoint.  It  would  vary  in 
different  States  and  with  different  judges  to  interpret  the  law. 
The  evidence  shows,  however,  that  in  many  places  and  under 
many  differing  circumstances  the  skiagraph  will  undoubtedly  be 
a  factor  in  medicolegal  cases. 

8.  The  technicalities  of  its  production,  the  manipulation  of 
the  apparatus,  etc.,  are  already  in  the  hands  of  specialists,  and 
with  that  subject  also  it  has  not  seemed  worth  while  to  deal. 
But  it  is  earnestly  recommended  that  the  surgeon  should  so 
familiarize  himself  with  the  appearance  of  skiagraphs,  with  their 
distortions,  with  the  relative  values  of  their  shadows  and  out- 
lines, as  to  be  himself  the  judge  of  their  teachings,  and  not  to 
depend  upon  the  interpretation  of  others,  who  may  lack  the  wide 
experience  with  surgical  injury  and  disease  necessary  for  the 
correct  reading  of  these  pictures. 


CHAPTER  XVIII 
THE  EMPLOYMENT  OF  PLASTER-OF-PARIS 

Many  of  the  fractures  of  the  upper  and  lower  extremities  may, 
at  some  period,  very  properly  be  treated  by  the  plaster-of-Paris 
splint. 

The  plaster-of-Paris  should  be  of  the  best  quality  and  dry. 
Crinoline  is  used  for  bandages.  Commercially  it  is  called 
Arrowwanna  Crinoline  Lining.  It  is  a  lining  material  that  is 
coarser  meshed  than  the  cheese-cloth  used  for  gauze  bandages, 
and  is  also  stiffer  than  cheese-cloth.  It  should  be  cut  into  four- 
yard  lengths,  folded,  and  stitched  together.  Crinoline  contains 
considerable  sizing  or  glue.  This  is  detrimental  to  its  use  as 
a  plaster  bandage.  It  should,  therefore,  be  washed  of  the  sizing 
in  lukewarm  water,  thoroughly  rinsed,  and  rough  dried.  The 
stitching  holds  the  material  firmly  together  during  the  washing. 
It  should  then  be  cut  into  strips  the  widths  of  the  desired 
bandages.  Three  widths  are  ordinarily  useful — namely,  widths 
of  two  inches,  three  inches,  and  five  and  one-half  inches.  These 
four-yard  strips  are  made  into  roller  bandages. 

Rolling  the  Plaster. — It  is  a  simple  matter  to  make  one's  own 
plaster  roller  bandages.  It  is  possible  to  purchase  plaster  ban- 
dages in  sealed  packages.  These  are  ordinarily  made  with  un- 
washed crinoline  and  are  less  desirable.  A  shallow  box  or  tray 
is  needed  to  hold  the  plaster.  Two  persons  can  roll  the  bandage 
with  facility.  "A"  manages  the  roll  of  crinoline,  straightens  it 
as  it  unwinds,  spreads  the  plaster  with  a  light  piece  of  board,  the 
size  of  the  hand,  while  "  B"  draws  the  crinoline  across  the  tray 
from  under  the  board  held  by  "A,"  and  rolls  up  the  bandage 
loosely  and  evenly.  "A"  with  the  board  held  still  and  plaster 
heaped  upon  the  bandage  behind  it,  regulates,  by  more  or  less 
pressure  upon  the  bandage,  the  amount  of  plaster  distributed 
over  the  crinoline.      It  requires   but  ten  or  fifteen   minutes  to 

425 


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427 


Fig.  590. —Lateral  or  side  splint  of  plaster-of-Paris  for  the  foot,  ankle,  and  lower  leg. 
Note  shape  of  crinoline.  The  plaster  cream  is  being  poured  from  pitcher  and  evenly  rubbed 
into  the  layers  of  crinoline. 


1  oo1  Porl  ion 


I  I  .it'  ral  01  side  splint  ol  plasti  1  of-Paris  ready  for  application  to  leg,  ankle,  and  foot. 

Plaster  cream  has  been  thoroughly  rubbed  into  the  meshes  of  the  crinoline. 


428 


Fig.  592. — Lateral  or  side  splint  of  plaster-of-Paris  applied  to  the  inner  side  of  leg,  ankle, 
and  foot.  Held  in  position  ready  for  bandage.  Note  the  perforated  tin  strip  at  the  ankle 
for  greater  strength.     Foot  at  right  angle  with  leg. 


Fig.  593-- 


-Lateral  or  side  splint  of  plaster-of-Paris.     Retentive  bandage  being  applied, 
reinforcing  strip  seen  at  the  ankle. 


Fig.  594. — Plaster  gutter  to  posterior  surface  of  leg  and  foot,  held  in  place  by  a  few  turns 
of  a  cheese-cloth  bandage.  This  plaster  posterior  splint  is  made  much  as  is  the  lateral  plaster 
splint  for  the  leg  and  foot. 

429 


43° 


THE    EMPLOYMENT    OF    PLASTER-OF-PARIS 


make  enough  bandages  for  a  plaster  splint  for  the  leg  or  thigh. 
An  advantage  in  making  one's  own  bandages  is  that  they  are 
made  of  the  desired  width  and  have  the  proper  amount  of 
plaster.  They  are  fresh  and  more  likely,  therefore,  to  set  readily 
upon  being  wet.  If  many  bandages  are  made  at  a  time,  they 
may  be  kept  in  a  tin  cracker  box.      If  the  closed  box  is  put  in  a 


Fig.  595-  —  Fracture  of  the  elbow  or  forearm.     Application  of  sheet  wadding  for  protection. 
Method  of  holding  the  arm  at  a  right  angle. 


dry  place,  these  bandages  will  keep  indefinitely.  Should  the 
plaster  become  damp,  the  bandages  should  be  placed  in  a  warm 
oven  until  dry.  It  is  important  in  making  the  plaster  rollers  to 
put  just  enough  plaster  into  the  bandage  and  to  distribute  the 
plaster  evenly  through  the  meshes  of  the  crinoline.  The  proper 
amount  of  plaster  to  put  into  a  bandage  can  only  be  learned  by 


MAKING    THE    PLASTER    liANDAGE 


431 


experience  in  making  and  using  the  bandages.  It  is  a  common 
error  to  spread  the  plaster  too  thickly.  The  water  in  which  the 
bandages  are  dipped  should  be  lukewarm  and  of  sufficient  depth 
to  cover  the  bandages  when  set  up  on  end.  The  water  working- 
its  way  into  the  meshes  of  the  bandage  displaces  the  air  in  the 
bandage,  which  is  indicated  by  the  bubbles  rising  to  the  surface 


Fig.  596. — Fracture  of  the  elbow  or  forearm.     Application  of  plaster-of-Paris  bandage. 
Method  of  holding  the  arm. 


of  the  water.  As  soon  as  the  bubbles  have  stopped  rising  the 
plaster  is  thoroughly  wet  throughout  the  bandage.  Table  salt, 
two  teaspoonfuls  to  four  quarts  of  water,  hastens  the  setting  of 
the  plaster.  Its  use,  however,  is  to  be  deprecated,  because  the 
plaster  has  to  be  applied  too  quickly  for  the  best  results  in 
plaster  work,  and  the  brittleness  of  the  plaster  resulting  from 
the   use  of  salt  is   undesirable.     The  plaster  bandage  should  be 


432 


THE    EMPLOYMENT    OF    PLASTER-OF-PARIS 


lifted  from  the  water  carefully  with  both  hands  holding  the  two 
ends  so  as  to  retain  as  much  plaster  as  possible  within  the  roll. 
The  bandage  should  then  be  wrung  free  from  water  while  the 
hands  still  grasp  its  ends.  The  bandage  should  be  wrung  until 
it  does  not  drip.  In  the  application  of  the  plaster  splint  to  frac- 
tures of  any  part  of  the  body  it  is  important  that  all  deformity 
should  be  corrected  and   that   the  part  should   be   thoroughly 


Fig.  59".— Fracture  of  the  elbow  or  forearm.     Plaster-of-Paris  splint  being  applied.     Elbow 

at  a  right  angle. 


immobilized.     This    necessitates   the    presence    of   one    or    two 
assistants. 

In  applying  a  plaster  splint  with  the  roller  bandage  the  sur- 
geon should  do  his  work  so  carefully  that  he  scatters  no  plaster 
anywhere  but  upon  the  splint  and  in  the  pail  of  water.  The 
surgeon  should  work  neatly.  The  patient  should  be  protected 
by  a  sheet.  The  floor  should  be  protected  by  a  sheet  spread 
under  the  patient  and  under  the  chair  of  the  surgeon.  The 
surgeon  should  remove  his  coat,  roll  up  his  sleeves,  and  be  pro- 
tected from  unexpected  spattering  of  plaster  by  an  apron  or 
sheet  over  his  body. 


APPLYING    THE    PLASTER    BANDAGE 


433 


One  thickness  of  sheet  wadding  torn  into  strips,  from  three  to 
five  inches  wide,  and  rolled  into  roller  bandages  and  then  applied 
to  the  limb  forms  the  best  protection  to  the  skin  in  applying  the 


Fig.  598. — Fracture  of  the  patella.     The  leg  covered  with  sheet  wadding.     The  application 
of  the  plaster-of-Paris  roller. 


Fig.  599. — Fracture  of  the  patella.     Application  of  the  plaster-of-Paris  roller.     Bandage  beinj 

finished. 


plaster  splint.  The  sheet  wadding  is  purchased  at  any  of  the 
dry-goods  stores.  It  may  be  purchased  by  the  quarter  bale  or 
by  the  single  sheet.     The  plaster  bandage  should  be  applied  to 

28 


434 


THE    EMPLOYMENT    OF    PLASTER-OF-PARIS 


the  protected  part  slowly,  deliberately,  and  accurately.  The 
bandage  should  be  applied  smoothly,  and  should  have  no  wrin- 
kles or  thick  awkward  places  anywhere.  It  is  well  to  rub  the 
bandage  as  fast  as  it  is  laid  upon  the  part  with  the  palm  of  the 
hand  slightly  wet  to  distribute  the  plaster  cream  thoroughly  and 
evenly.  Over  bony  prominences  the  bandage  should  be  very 
carefully  molded.  This  will  insure  a  good  fit  and  less  likelihood 
of  slipping  upon  change  of  position.  It  is  well  to  carry  the  first 
roll  of  plaster  as  far  as  it  will  go,  one  or  two  layers  thick,  com- 
pleting the  whole  splint  once,  and  then  to  go  over  it  again  from 


» 

A 

, 

— — ^^^ 

1                               • 

Fig.  600.— Fracture  of   the  leg.     Plaster-of-Paris  splint  applied    from  the  toes  to  the  groin. 
Foot  at  a  right  angle  with  the  leg.     Toes  padded  to  prevent  chafing. 


beginning  to  end.  A  sufficient  number  of  layers  should  be  ap- 
plied to  make  a  firm  enough  splint  for  the  support  of  the  part 
when  the  plaster  has  set.  The  splint  should  be  as  light  as  is 
compatible  with  strength.  Light  splints,  if  accurately  fitted, 
accomplish  more  good  than  heavy,  ill-fitting  ones.  It  is  better  to 
use  too  few  rolls  of  plaster  bandage  rather  than  so  many  that  a 
heavy  and  cumbersome  splint  is  made.  Immediately  after  the 
plaster  has  set,  if  it  is  found  to  be  too  weak  at  any  spot,  an 
additional  bandage  may  be  used  to  reinforce  at  that  point. 
The  part  bandaged  should  be  held  in  perfect  position  until  the 
plaster  has  set  firmly  enough  to  support  it.     This  will  ordinarily 


Fig.  601. — Fracture  of  the  leg.     Plaster  cast  of  leg  from  toes  to  below  the  knee  removed. 


Fig.  602. — Fracture  of  the  leg.     Removable  plaster  cast  of  leg.    Same  as  figure  601.     Anterior 
view,  showing  cut  in  plaster. 

435 


436 


THE    EMPLOYMENT    OF    PLASTER-OF- PARIS 


occur  in  about  ten  or  fifteen  minutes.  The  weight  of  the  splint 
may  be  materially  reduced  by  using  tin  strips  incorporated  in  the 
layers  of  the  plaster  bandage.  These  strips  should  be  perforated 
by  holes  so  as  to  offer  rough  places  to  catch  in  the  plaster 
bandage.  The  two  ends  of  the  splint  should  be  so  finished  that 
pressure  and  consequent  deformity  can  not  occur — for  instance, 
the  plaster  of  the  forearm  should  stop  just  short  of  the  bend  of 
the  elbow.      The  plaster  of  the  thigh  should   be  so  far  below  the 


Fig.  603. — Open  fracture  of  the  leg.    Plaster-of-Paris  splint.     Window  cut  in  plaster  through 
which  wound  is  dressed.     Window  surrounded  by  oiled  silk. 


perineum  and  groin  as  to  permit  of  flexion  of  the  thigh  upon 
the  trunk  without  excoriating  the  skin  of  the  groin.  The  toes 
and  fingers  should  be  left  uncovered  to  admit  of  inspection. 

A  great  degree  of  skill  is  demanded  upon  the  part  of  the 
surgeon  for  the  proper  application  of  the  plaster-of- Paris  splint. 
Plaster- of- Paris,  when  used  for  fractured  bones,  is  applied  either 
before  or  after  the  swelling  has  taken  place  :  if  applied  before, 
it   constricts   the    seat    of  fracture,   prevents   swelling,  and    may 


APPLYING    THE    PLASTER    BANDAGE  437 

cause  great  pain  ;  if  applied  after  the  swelling  has  taken  place,  it 
becomes  loose  as  soon  as  the  swelling  of  the  soft  parts  subsides, 


Fig.  604. — Open  fracture  of  the  ankle.     Window  in  plaster-of-Paris  splint  through  which 
wound  is  dressed.     Gauze  seen  in  the  window.     Oiled  silk  about  the  window. 


Fig.  605. — Fracture  of  the  patella.     Leather  knee-cap  with  hooks  for  lacing.     Made  from 
plaster  cast.     Worn  as  a  protection  to  knee  after  fracture. 

and  motion  of  the  limb  in  the  splint  and  of  the  fragments  of  the 
fractured  bone   one  upon  the  other  is  possible.      It  is  important, 


438 


THE    EMPLOYMENT    OF    PLASTER-OF-PARIS 


therefore,  to  split  the  plaster  soon  after  it  has  been  applied,  and 
thus  obviate  these  dangers  of  too  light  and  too  loose  a  splint. 
The  tightness  of  the  splint  should  be  regulated  by  straps  and  a 
bandage  of  cheese-cloth. 

The  Removal  of  the  Plaster  Splint. — The  removal  of  the 
plaster  splint  is  difficult.  No  instrument  has  been  devised  that 
is  more  efficient  than  an  ordinary  sharp  jack-knife.  If  the 
plaster  splint  is  split  immediately  after  its  application, — i.  e.,  as 
soon  as  it  is  hard, — it  will  be  far  easier  than  if  it  is  cut  after  it  is 


Fig.  606. — Fracture  of  the  leg.     Removable 
dextrin  splint  with  hooks  and  lacing. 


Fig.  607. — Fracture  of  the  leg.     Same  as 
figure  606.     Anterior  view. 


thoroughly  dry.  A  strip  of  tin  an  inch  wide  laid  upon  the  pro- 
tected 'eg  and  covered  by  the  plaster  in  its  application  will  often 
be  of  great  service  upon  removing  the  plaster.  The  tin  will 
serve  as  a  protection  to  the  skin,  and  the  cutting  may  be  done 
more  quickly  and  easily. 

After  removing  most  of  the  plaster  from  his  hands  the  surgeon 
should  wash  his  hands  with  a  little  water  and  granulated  sugar 
or  molasses.  The  sugar  assists  in  removing  all  traces  of  plaster 
and  leaves  the  skin  soft  and  clean.  Bandages  of  plaster-of- Paris 
are   so   readily   obtained,    so   efficient,  so   safe   from    interference 


THE    DEXTRIN    BANDAGE  439 

upon   the  part   of  the  patient,  and   so   easy  to   apply,  that  it  is 
surprising  they  are  not  applied  more  often  than  they  are. 

The  dextrin  bandage  is  much  slower  in  becoming  firm  than 
the  plaster  bandage,  and  is  very  light  and  serviceable.  It  is 
applied  exactly  as  is  the  plaster-of-Paris  bandage.  The  roller 
bandage  of  cotton  cloth  is  first  unrolled  and  rerolled  in  a 
basin  containing  a  watery  solution  of  powdered  dextrin.  For- 
mula for  making  the  solution  of  dextrin  :  Add  about  four- 
teen ounces  of  powdered  dextrin  to  a  pint  of  water,  boil  until 
dissolved,  strain,  and  add  one  ounce  of  alcohol.  The  bandage 
is,  therefore,  thoroughly  saturated  with  the  dextrin  solution. 
After  covering  the  part  bandaged  once,  dextrin  is  painted, 
with  a  small  paint-brush,  over  the  bandage.  This  is  allowed 
to  dry  before  a  second  and  a  third  layer  of  the  bandage  are 
applied.  After  each  bandage  a  coating  of  dextrin  is  applied. 
After  the  final  bandage  several  coatings  of  dextrin  are  applied, 
until  a  shiny,  smooth  surface  results.  This  bandage  maybe  cut, 
and,  by  the  addition  of  strips  of  leather  along  the  cut  edge  upon 
which  are  hooks,  may  be  laced  and  unlaced  as  necessary  (see 
Figs.  596,  597). 


CHAPTER  XIX 
THE  AMBULATORY  TREATMENT  OF  FRACTURES 

Bv  the  ambulatory  treatment  of  fractures  of  the  lower  ex- 
tremity is  understood  a  method  of  treatment  that  permits  the 
immediate  and  continued  use  of  the  injured  limb  as  a  means  of 
locomotion. 

Medical  literature  contains  many  references  to  this  method.  It 
has  been  in  use  for  some  ten  years.  It  has  not  met  with  general 
acceptance  even  among  hospital  surgeons.  It  is  a  radical  method 
and  open  to  criticism.  It  contains,  however,  several  important 
suggestions.  It  will  prove  instructive  to  follow  the  adoption  of 
this  method  by  its  advocates,  and  to  discover,  if  possible,  what 
there  is  in  it  of  permanent  value. 

Orthopedic  surgeons  as  early  as  1878  conceived  the  idea  of 
allowing  a  patient  with  a  fracture  of  the  thigh  or  of  the  leg  to 
walk  about  by  means  of  apparatus.  Thomas,  of  Liverpool,  and 
Dowbrowski  used  the  Thomas  knee-splint  in  the  treatment  of 
fractures  certainly  as  early  as  the  year  1881  or  1882.  Krause,  a 
German  surgeon,  published,  in  1891,  the  first  account  of  the 
treatment  of  fractures  of  the  bones  of  the  leg  in  walking  patients. 
Krause  demonstrated  that  plaster-of- Paris  could  be  used  as  a 
splint  in  fractures  of  the  leg  and  in  transverse  fractures  of  the 
thigh.  Korsch,  in  1894,  presented  a  paper  to  the  German  Sur- 
gical Congress  demonstrating  that  compound  fractures  of  the  leg 
and  fractures  of  the  thigh  may  be  treated  with  plaster-of-Paris 
splints  and  early  use.  Korsch  makes  permanent  extension  in  a 
thigh  fracture,  while  traction  is  maintained  by  an  assistant, 
by  applying  the  plaster  directly  to  the  skin,  snugly  to  the 
malleoli,  the  dorsum  of  the  foot,  and  the  heel.  A  padded  ring 
is  incorporated  into  the  upper  limit  of  the  plaster  splint  around 
the  thigh,  which  presses  against  the  tuberosity  of  the  ischium,  and 
thus  accomplishes  counterextension.    Korsch's  cases  were  treated 

440 


HISTORICAL    CONSIDERATIONS  44  I 

in  Bardeleben's  clinic.  Bruns,  of  Tubingen,  in  1893,  described 
a  splint  for  use  in  these  cases  of  fracture  of  the  leg  and  thigh. 
Dollinger,  of  Budapest,  in  1893,  described  a  splint  for  the 
ambulatory  treatment  of  fractures  of  both  bones  of  the  leg,  and 
reported  three  cases.  Dollinger's  method  of  applying  the 
plaster-of-Paris  splint  is  the  one  generally  used  whenever  the 
ambulatory  treatment  is  employed.  The  method  is  described 
later. 

Warbasse,  at  the  Methodist  Episcopal  Hospital  of  Brooklyn, 
N.  Y.,  in  1893,  was  the  first  in  this  country  to  adopt  systemat- 
ically Dollinger's  method.  Warbasse  reports  six  cases — all  in 
young  adults.  Bardeleben  reported,  in  1894,  one  hundred  and 
sixteen  cases  treated  with  walking  splints.  There  were  eighty- 
nine  fractures  of  the  leg,  complicated  and  uncomplicated  ;  five 
fractures  of  the  patella  ;  twenty-two  fractures  of  the  thigh,  five 
of  which  were  compound  ;  three  cases  of  osteotomy  for  genu 
valgum.  Bardeleben  lays  down  the  following  law  :  "  It  is  of  the 
greatest  advantage  to  the  patient  that  such  a  dressing  can  be 
applied  to  the  broken  leg  that  he  can  bear  the  weight  of  the  body 
upon  it  and  walk  about  ;  but  such  a  method  of  treatment  should 
be  applied  only  under  medical  supervision,  and  with  the  most 
careful  consideration  of  complications  that  might  arise."  Korsch 
presented  to  the  German  Surgical  Congress,  in  1894,  seven 
cases — three  of  the  thigh  and  four  of  the  leg.  Albers,  in  1894, 
reported  seventy-eight  cases  (fifty-six  of  the  leg,  five  of  the 
patella,  sixteen  of  the  thigh,  and  one  of  the  leg  and  thigh) 
treated  by  the  ambulatory  method.  He  seems  to  be  a  little 
more  cautious  than  other  German  surgeons  in  this  matter.  He 
says  that  when  great  pain  is  present,  it  is  best  to  employ  injec- 
tions of  morphin. 

Elevation  of  the  limb  will  often  reduce  the  swelling  ;  when 
this  does  not  suffice,  the  bandage  must  be  removed.  Severe  local 
pain  from  pressure  indicates  the  necessity  for  cutting  a  fenestrum. 
The  first  attempt  at  walking  should  be  made  on  the  day  follow- 
ing the  application  of  the  cast.  A  crutch  and  cane  are  used  at 
first ;  later,  two  canes  are  employed  ;  and,  finally,  some  patients 
walk  without  any  support  at  all.  Krause,  in  1894,  reported 
seventy-two  cases  treated.      He  is  of  the  opinion  that  the  ambu- 


442  THE    AMBULATORY    TREATMENT    OF    FRACTURES 

latory  treatment  in  plaster  splints  must  be  limited  principally  to 
fractures  and  osteotomies  in  the  region  of  the  malleoli,  the  leg, 
and  the  lower  end  of  the  thigh.  He  does  not  employ  the  method 
in  the  handling  of  oblique  fractures  of  the  femur  and  fractures  of 
the  neck  of  the  femur.  Bardeleben  writes  again  in  1895,  report- 
ing up  to  that  date  one  hundred  and  eighty-one  cases  treated  by 
the  ambulatory  treatment.  This  last  report,  of  course,  included 
the  one  hundred  and  sixteen  cases  of  the  previous  record.  Dr. 
Edwin  Martin,  before  the  Surgical  Section  of  the  College  of 
Physicians  of  Philadelphia  on  December,  1895,  reported  twenty 
cases  of  fracture  of  the  leg  treated  by  this  method.  Dr.  E.  S. 
Pilcher,  of  Brooklyn,  N.  Y.,  in  whose  wards  Warbasse  worked, 
reported  to  the  American  Surgical  Association  the  twenty  or 
more  cases  treated  by  him  in  which  the  results  were  satisfactory. 
N.  P.  Dandridge,  of  Cincinnati,  Ohio,  has  used  the  method  in 
eight  cases.  In  most  of  the  cases  pain  was  complained  of  when 
weight  was  borne  on  the  foot.  In  a  feeble  woman  it  was  neces- 
sary to  remove  the  cast  in  the  third  week.  In  the  case  of  a  man, 
— a  compound  fracture  of  the  leg, — after  walking  two  weeks  he 
had  so  much  pain  that  the  plaster  was  removed.  Redness  and 
swelling  were  great  at  the  seat  of  fracture,  and  there  was  much 
swelling  over  the  internal  malleolus.  Woodbury  introduced  the 
method  at  Roosevelt  Hospital,  New  York  city,  and  Fiske  has  re- 
ported cases  treated  at  that  clinic.  Roberts,  of  Philadelphia,  and 
Woolsey,  of  New  York,  have  used  the  method  in  selected 
cases  with  satisfaction.  A.  T.  Cabot,  of  Boston,  has  used,  in 
several  fractures  of  the  femur,  Taylor's  long  hip-splint.  E.  H. 
Bradford,  of  Boston,  has  treated  cases  of  fracture  at  the  Chil- 
dren's Hospital  by  a  modified  Thomas  knee  splint,  with  and 
without  plaster-of-Paris  splinting  (Fig.  608). 

Those  advocating  the  ambulatory  treatment  suggest  its  appli- 
cation to  fractures  of  the  leg  below  the  knee,  both  simple  and 
compound,  and  in  fractures  of  the  lower  end  of  the  femur.  The 
apparatus  is  not  to  be  applied  for  three  or  four  days  if  there  is 
much  primary  swelling. 

The  method  of  application  of  the  plaster  splint  in  the 
ambulatory  treatment  of  fractures  of  the  tibia  and  fibula  alone 
is  as  follows  (this  is  practically  the  method  of  Dollinger) :   First 


THE    METHOD    APPLIED    TO    THE    TIBIA    AND    FIBULA 


443 


comes  the  cleansing  of  the  skin  of  the  leg  with  soap  and  water 
and  then  the  reduction  of  the  fracture.  Then,  with  the  foot 
fixed  at  a  right  angle  to  the  leg,  a  flannel  bandage  is  smoothly 
and  evenly  applied  from  the  toes  to  just  above  the  knee.  This 
bandage  is  made  to  include  beneath  the  sole  of  the  foot  a  pad- 
ding of  ten   or  fifteen   layers   of  cotton  wadding,  making  a  pad 


a. 


£. 


Fig.  60S. — Thomas  knee  splint  for  ambulatory  treatment  of  leg  fractures,  used  with  a  light 
plaster-of-Paris  leg  splint :  a,  ordinary  form  ;  6,  "  caliper  "  or  convalescent  splint  so  fitted  as 
to  keep  the  heel  of  the  foot  away  from  the  boot  while  the  toes  are  used;  c,  the  half-ring 
sometimes  used  at  the  upper  end  ;' d,  lower  end  of  splint,  as  arranged  for  windlass  traction. 


about  three-fourths  of  an  inch  thick,  after  it  is  compressed  by 
the  moderate  pressure  of  the  flannel  bandage.  Over  this  is  now 
applied  the  plaster  bandage  from  the  base  of  the  toes  to  just 
above  the  knee,  especial  care  being  taken  that  the  application  is 
made  smoothly  and  somewhat  more  firmly  than  is  the  custom  in 
the  ordinary  plaster  cast.  The  layers  of  the  bandage  should  be 
well  rubbed  as  they  are  applied,  with  a  view  to   obtaining  the 


444  THE    AMBULATORY    TREATMENT    OF    FRACTURES 

greatest  amount  of  firmness  with  the  smallest  amount  of  material. 
The  sole  is  strengthened  by  incorporating  with  the  circular 
turns  an  extra  thickness  composed  of  ten  or  twelve  layers  of 
bandage  well  rubbed  together,  and  extending  longitudinally  along 
the  sole.  The  bandage  is  applied  especially  firmly  about  the 
enlarged  upper  end  of  the  tibia,  and  here  it  is  made  somewhat 
thicker.  As  it  dries  it  may  be  pressed  in  so  as  to  conform  more 
closely  to  the  leg  just  below  the  heads  of  the  tibia  and  fibula. 
The  assistant  who  stands  at  the  foot  of  the  table  and  supports 
the  leg  makes  such  traction  or  pressure  as  is  required  to  keep 
the  fragments  in  proper  position  while  the  plaster  is  being 
applied.  The  operation  requires  about  twenty  minutes,  and  by 
the  time  the  last  bandage  is  applied  the  cast  should  be  fairly 
hard. 

It  is  seen  that  when  this  cast  has  become  hardened  the  leg  is 
suspended.  When  the  patient  steps  upon  the  sole  of  the  plas- 
ter cast,  the  thickness  of  the  cotton  beneath  the  foot  separates 
the  sole  of  the  foot  so  far  from  the  sole  of  the  cast  that  the  foot 
hangs  suspended  in  its  plaster  shoe.  Thus  the  weight  of  the 
body,  which  would  come  upon  the  foot,  is  borne  by  the  diverging 
surface  of  the  leg  above  the  ankle.  The  chief  of  these  is  the 
strong  head  of  the  tibia.  A  lesser  role  is  played  by  the  head  of 
the  fibula  and  the  tapering  calf  in  muscular  subjects. 

In  thigh  fractures  the  use  of  the  long  Taylor  hip-splint, 
together  with  a  high  sole  upon  the  well  foot  and  crutches,  is 
generally  accepted  as  the  best  method  of  ambulatory  treat- 
ment. 

The  advantages  claimed  for  the  ambulatory  method  are  : 

Time  is  saved  to  the  business  man  by  this  method — he  having 
to  give  up  but  about  seven  days  to  a  fracture  of  the  leg.  The 
time  spent  by  the  patient  in  the  hospital  is  less  than  by  other 
methods.  The  general  health  is  conserved  ;  whereas  by  the  old 
method  the  appetite  is  variable,  sleep  is  troubled,  the  bowels  are 
constipated,  and  general  discomfort  prevails.  There  is  greater 
general  comfort  by  this  method  than  by  any  other.  In  drunk- 
ards and  those  with  a  tendency  to  delirium  tremens  this  liability 
is  greatly  diminished.  In  old  people  the  danger  of  a  hypo- 
static pneumonia  is  lessened.     The  primary  swelling  associated 


THE    ADVANTAGES    CLAIMED    FOR    THE    METHOD  445 

with  a  fracture  is  often  avoided,  and  always  less  than  by  the 
older  methods.  The  secondary  edema  and  muscular  weak- 
ness are  less.  The  functional  usefulness  of  the  whole  leg  is 
greater.  There  is  less  atrophy  of  the  muscles  of  the  thigh  and 
leg".  The  amount  of  the  callus  is  diminished.  There  is  less 
stiffness  of  neighboring  joints.  Union  in  a  fracture  occurs  at  an 
earlier  date. 

Before  this  method  can  be  adopted  generally  and  in  hospital 
treatment  it  must  be  demonstrated  that  it  is  safe,  and  that  it  offers 
chances  of  better  functional  results  than  are  obtained  under 
present  methods,  and  that  the  minor  advantages  claimed  for  it  by 
ardent  German  advocates  are  real  and  not  imaginary.  The  first 
great  advantage  of  the  method  is  stated  to  be  that  the  stay  in  the 
hospital  and  the  time  away  from  one's  occupation  are  much 
lessened.  Regarding  this  point  the  Massachusetts  General 
Hospital  Surgical  Records  were  consulted  for  these  three  periods  : 
before  the  use  of  plaster-of-Paris — that  is,  previous  to  1865  ;  just 
at  the  beginning  of  the  use  of  plaster-of-Paris  as  a  splint  for  frac- 
ture, and  in  1895,  1896,  and  1897.  Thirty-five  unselected  cases 
of  fracture  of  the  tibia  and  fibula  were  tabulated  from  each  period. 
The  duration  of  the  average  time  spent  in  the  hospital  in  the  first 
period — i.e.,  previous  to  1865 — was  forty-six  days;  in  the 
second  period — i.  e.,  about  1866 — it  was  forty-five  days  ;  at  the 
present  time  it  is  sixteen  days.  In  the  second  period  plasters 
were  applied  to  fractured  legs  on  an  average  at  about  the  twenty- 
eighth  day  ;  at  the  present  time,  on  the  fourteenth  day.  In  other 
words,  there  has  been  since  the  introduction  of  the  plaster  splint 
a  gradually  shorter  detention  in  the  hospital,  as  surgeons  have 
come  to  recognize  the  safety  of  an  earlier  application  of  a  fixed 
dressing.  On  an  average,  patients  with  fracture  of  the  leg  are 
detained  in  the  hospital  to-day  but  sixteen  days.  The  very 
great  saving  to  the  hospital  in  time  by  the  ambulatory  treatment 
does  not,  therefore,  appear.  It  is  impossible  to  consider  the 
statements  made  with  regard  to  rapidity  of  healing,  sign  of  callus, 
absence  of  muscular  atrophy,  and  absence  of  rigidity  of  joints, 
because  there  are  no  facts  available  for  the  purpose.  The  advan- 
tages stated  are  based,  most  of  them,  upon  the  personal  impres- 


446      THE  AMBULATORY  TREATMENT  OF  FRACTURES 

sions  of  the  surgeon  in  charge  ;  impressions  compared  with 
scientific  observations  are  untrustworthy. 

Krause  presents  a  table  from  Paul  Bruns  containing  the  aver- 
age periods  of  healing  in  a  series  of  fractures,  and  compares  these 
periods  with  his  own  fracture  cases  treated  by  the  ambulatory 
method.  This  is  the  only  attempted  scientific  statement  of  obser- 
vation on  this  important  point.  Krause  concludes  from  a  study 
of  these  tables  that,  "  In  the  treatment  of  fractures  of  the  middle 
and  upper  thirds  of  the  leg,  the  ambulatory  method  shows  a  great 
advantage  in  the  period  of  consolidation  as  well  as  in  the  time 
when  the  patient  can  return  to  work.  It  seems  that  the  higher 
up  the  fracture  is  in  the  leg,  the  sooner  a  cure  is  effected  by  the 
ambulatory  method  of  treatment." 

Conclusions. — A  review  of  the  literature  does  not  disclose 
any  other  advantage  in  the  results  of  the  ambulatory  treatment 
over  the  present  treatment  of  fractures  of  the  leg  than  that  stated 
by  Krause.  The  present  commonly  accepted  method  of  treating 
fractures  of  the  femur  by  long  rest  in  the  horizontal  position, 
with  extension  by  weight  and  pulley,  is  not  satisfactory.  The 
protracted  stay  in  bed  is  undesirable.  The  use  of  the  Taylor 
hip-splint  in  the  treatment  of  this  fracture,  assisted  by  coaptation 
splints  or  a  splint  of  plaster-of-Paris,  is  of  distinct  value.  This, 
however,  is  a  somewhat  well-known  method  of  ambulatory 
treatment. 

Theoretically  and  practically,  the  ambulatory  treatment  does 
not  perfectly  immobilize  ;  therefore,  it  can  not  preeminently  suc- 
ceed as  a  means  of  treatment.  The  method  in  general  seems  to 
be  unsurgical.  Embolism,  both  of  fat  and  of  blood,  and  the 
likelihood  of  pressure-sores  in  the  use  of  the  plaster  splint  are 
dangers  to  be  considered.  It  is  wise  to  allow  the  injured  limb 
to  rest  while  the  reparative  process  is  beginning.  Muscular 
relaxation  is  desirable  in  the  treatment  of  fractures.  The  very 
admission  by  the  advocates  of  the  ambulatory  treatment  that 
muscular  contractions  take  place  is  reason  enough  for  supposing 
that  complete  immobilization  is  not  obtained  by  this  method. 
However,  in  certain  carefully  selected  cases  of  fracture  below 
the  knee,  particularly  of  the  fibula,  if  under  the  care  of  a  com- 


THE    ADVANTAGES    CLAIMED    FOR    THE    METHOD  447 

petent  and  skilful  surgeon,  it  is  possible  to  conceive  of  the  ambu- 
latory method  being  used  without  doing  harm. 

A  consideration  of  the  ambulatory  treatment  of  fractures 
should  lead  to  a  more  careful  and  early  use  of  the  plaster-of- 
Paris  splint  in  fractures  of  the  leg,  and  to  a  proper  application  of 
the  long  hip-splint  or  its  equivalent  in  fractures  of  the  thigh,  and 
to  the  early  use  of  crutches  and  the  high  sole  on  the  well  foot  in 
both  of  these  lesions. 

Materials    for   the  Ordinary  Care  of    Closed   Fractures 

The  materials  with  which  a  physician  should  be  provided  in 
order  to  properly  care  for  the  fractures  ordinarily  met  with  are 
comparatively  few. 

There  is  scarcely  a  fracture  which  can  not  be  treated  satisfac- 
torily by  the  proper  use  of  plaster-of-Paris. 

Plaster-of- Paris  roller  bandages. 

Washed  crinoline. 

Plaster-of-Paris. 

A  jack-knife,  for  splitting  plaster  dressings. 

A  pair  of  heavy  scissors. 

Thin  splint  wood,  -^  of  an  inch  in  thickness. 

Iron  wire,  ]/±  of  an  inch  in  diameter. 

Posterior  wire  splint,  for  adult  leg. 

Anterior  wire  splint,  for  adult  leg. 

Surgeon's  adhesive  plaster. 

Cotton  and  cheese-cloth  roller  bandages. 

Sheet  wadding  for  padding  splints. 


BIBLIOGRAPHY 

The  important  contributions  to  literature  which  have  been  consulted  are  recorded 
below.  Dr.  Stimson's  book  upon  "  Fractures  "  will  always  stand  as  a  classical  work 
in  its  especial  field.  Dr.  Poland's  work  upon  "The  Epiphyses"  is  also  a  very- 
valuable  contribution  to  fracture  literature.  The  text  has  been  kept  free  of  all 
references  in  order  that  greater  clearness  might  result. 


Hamilton,  Fractures  and  Dislocations. 

Stimson,  A  Practical  Treatise  on  Fractures  and  Dislocations,  Lea  Bros.,  1899. 

Helferich,  Atlas  of  Traumatic  Fractures  and  Luxations,  with  a  Brief  Treatise,  Wm. 

Wood&  Co.,  1896. 
Roberts,  P.  Blakiston,  Son  &  Co.,  Philadelphia,  1897. 
Wharton  and  Curtis,  The  Practice  of  Surgery. 

The  International  Encyclopedia  of  Surgery  ;  supplementary  volume  vii,  1895. 
Dennis,  F.  S.,  System  of  Surgery,  1895. 
Cheever,  Lectures  on  Surgery,  Damrell  and  Upham,  Boston,  1894. 


FRACTURE  OF  THE  SKULL 

Huguenin,  Cyclopaedia  practische  Medicin,  Ziemssen,  Band  XII,  1897. 

Mills,  The  Nervous  System  and  Its  Diseases,  1898. 

Bradford  and  Smith,  Transactions  of  the  American  Surgical  Association,  volume 

LX,  page  433. 
Bullard,  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  1897. 
Dana,  Text-book  of  Nervous  Diseases. 

Courtney,  Boston  Medical  and  Surgical  Journal,  April  6,  1899,  page  345. 
Hill  and  Bayliss,  Journal  of  Physiology,  London,  1S95,  xviii,  page  324. 
Walton,  American  Journal  of  Medical  Sciences,  September,  1898. 
Putnam,  Walton,  Scudder,  Lund,  American  Journal  of  Medical  Sciences,  April, 

1895. 

FRACTURE  OF  THE  NASAL  BONES 

Bosworth,  Diseases  of  Nose  and  Throat,  third  edition,  pages  157-161. 

Zuckerkandl,  Anat.  norm,  et  Patholog.  des  Fosses  Nasales,  volume  1,  page  429. 

Evans,  Deflections  of  the  Nasal  Septum,  Louisville  Journal  of  Surgery  and  Medi- 
cine,, volume  V,  June,  189S,  pages  1-4. 

Casselberry,    Deformities  of  the   Septum    Narium,  Transactions  of  the  American 
Medical  Association,  volume  XXII,  No.  9,  pages  469-471. 

Cobb,  Fracture  of  the  Nasal  Bones,  Journal  of  the  American  Medical  Association, 
volume  xxx,  189S,  page  588. 

Freytag,  Monatsschrift  fur  Ohrenheilkunde,  1896,  Band  XXX,  Seiten  217-224. 

Zuckerkandl,  Anatomie  der  Nasenhohle,  Band  II. 
29  449 


450  BIBLIOGRAPHY 

Watsin,  Lancet,  1896,  volume  1,  page  972. 

Roe,  The  American  Medical  Quarterly,  June,  1899. 

FRACTURE  OF  THE  SPINE 
Thorburn,  A  Contribution  to  the  Surgery  of  the  Spinal  Cord. 
Walton,  Boston  Medical  and  Surgical  Journal,  December  7,  1893. 
Thomas,  Boston  Medical  and  Surgical  Journal,  September  7,  1899,  page  233. 
Dennis,  Annals  of  Surgery,  March,  1895. 

Burrell,  Transactions  of  the  Massachusetts  Medical  Society,  1887. 
Taylor,  Journal  of  the  Boston  Society  of  the  Medical  Sciences,  December,  1898. 
Wagner  and   Stolper,  Die  Verletzungen  des  Wirbelsaule  und  des  Riickenmarks, 

1898,  Seite  415. 
Kocher,  Mittheilungen  Grenzgebieten  der  Medicin  und  Chirurgie,  1896. 
White,  Transactions  American  Surgical  Association,  vol.  IX. 
Cheever,  Boston  Medical  and  Surgical  Journal,  September  28,  1 893. 
Pilcher,  Annals  of  Surgery,  volume  XI,  pages  187-200. 
Prewitt,  Transactions  American  Surgical  Association,  volume  XVI,  page  255. 

FRACTURE  OF  THE  SCAPULA 
Blake,  Boston  City  Hospital  Reports,  1899,  page  36S. 

FRACTURE  OF  THE  HUMERUS 

Bruns,  Deutsche  Chirurgie,  Theil  28,  2.  Halfte. 

Murray,  New  York  Medical  Journal,  June  25,  1892. 

Monks,  Boston   City   Hospital    Medical   and    Surgical   Reports,    1895;    also  Boston 

Medical  and  Surgical  Journal,  March  21,  1S95,  January  9,  1896,  and  December 

4,  1895. 
Lund,  Boston  City  Hospital  Reports  for  1897,  page  389. 

Allis,  Annals  of  the  Anatomical  and  Surgical  Society,  Brooklyn,  1880,  II,  289. 
Smith,  Boston  Medical  and  Surgical  Journal,  July,  1895. 
Stimson,  Roberts,  Allis,  Transactions  of  the  American  Surgical  Association,  1881 

to  1898. 

FRACTURE  OF  THE  FOREARM 

Pilcher,  Paper  read  to  Association  of  Military  Surgeons  of  the  United  States,  Berlin 
Printing  Co.,  Columbus,  Ohio.  Medical  Record,  1878,  11,  74.  Annals  of  An- 
atomical and  Surgical  Association,  Brooklyn,  1887,  III,  page  ^3- 

Moore,  Transactions  of  the  Medical  Society,  State  of  New  York,  1880. 

Bolles,  Boston  City  Hospital  Reports,  third  series,  1882,  page  340. 

Conner,  Journal  of  the  American  Medical  Association,  1894,  page  54. 

Roberts,  Medical  News.  1890,  i.vii,  615.      Annals  of  Surgery,  1892,  XXL 

Mouchet,  A.,  Revue  de  Chirurgie,  May,  1900. 

FRACTURE  OF  THE  THIGH 
Cabot,  Boston  Medical  and  Surgical  Journal,  January  3,  1884,  page  6. 
Allis,  Transactions  of  the   American    Surgical    Association,  volume   IX,  1891,   page 
329.      Medical  News,  November  21,  1891. 


lillJLIOG.RAPHY  451 

Hutchinson,  Lancet,  1898,  11,  1630. 

Packard,  International  Encyclopaedia  of  Surgery. 

Whitman,  Annals  of  Surgery,  June,  1897,  page  I. 

Senn,  Journal  of  the  American  Medical  Association,  August  3,  1889. 

Ridlon,  Transactions  of  the  American  Orthopedic  Association,  1897,  page  186. 

Lane,  Medicochirurgical  Transactions,  London,  1888. 

Scudder,  Boston  Medical  and  Surgical  Journal,  March  22,  29,  1900. 

SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  FEMUR 

Annals  of  Surgery,  Philadelphia,  1S98,  xxvill,  664. 

Annals  of  Gynecology,  November,  1890. 

British  Medical  Journal,  December,  1894,  page  671. 

New  York  Medical  Record,  October  5,  1895. 

Annals  of  Surgery,  March,  1896. 

Archives  Generales,  March  and  April,  1884,  volume  XIII,  page  272. 

Transactions  of  the  American  Surgical  Association,  1895. 

Liverpool  Medicochirurgical  Journal,  January,  1885,  page  41. 

Liverpool  Medicochirurgical  Journal,  July,  1883. 

Stimson,  Fractures  and  Dislocations,  1899. 

Hutchinson,  Lancet,  May  13,  1899. 

McBurney,  Annals  of  Surgery,  March,  1896,  xxn,  506. 

Harte,  Transactions  of  the  American  Surgical  Association,  1895. 

Deleus,  Archives  Generale  de  Medicine,  1884,  volume  XIII,  page  272. 

Poland,  Traumatic  Separation  of  the  Epiphyses,  1898. 

Smith,  Transactions  of  the  American  Surgical  Association,  volume  VIII. 

FRACTURE  OF  THE  PATELLA 

Powers,  Annals  of  Surgery,  July,  1898. 

Bull,  New  York  Medical  Record,  xxxvn,  1890. 

McBurney,  Annals  of  Surgery,  1895,  XXI,  312. 

Pilcher,  Annals  of  Surgery,  1890,  XII. 

Stimson,  Annals  of  Surgery,  1895,  XXI,  603  ;    1896,  xxiv,  45. 

Cabot,  Boston  Medical  and  Surgical  Journal,  cxxv. 

Dennis,  System  of  Surgery. 

Lund,  Boston  Medical  and  Surgical  Journal,  1896,  cxxxv    338. 

Fowler,  Annals  of  Surgery,  January,  1891. 

Macewen,  Annals  of  Surgery,  1887,  volume  V,  page   177. 

Phelps,  New  York  Medical  Journal,  June,  1890. 

White,  New  York  Medical  Record,  October  27,  1888. 

Beach,  New  York  Medical  Record,  March  15,  1890. 

FRACTURE  OF  THE  LEG 

Cabot,  The  Boston  Medical  and  Surgical  Journal,  January  3,  1894,  page  6. 

Lovett,  Boston  City  Hospital  Medical  Reports,  1899,  page  222. 

Allis,  Annals  of  Surgery,  1897. 

Tiffany,  Annals  of  Surgery,  1896,  XXIII,  449. 

Lane,  Transactions  of  the  Clinical  Society,  London,  xxvir,  167. 


452  BIBLIOGRAPHY' 

Stimson,  New  York  Medical  Journal,  June  25, 1892. 

Smith,  N.  R.,  Treatment  of  Fractures  of  the  Lower  Extremity,  Baltimore,  Kelly 
and  Piet,  1867. 

THE  AMBULATORY  TREATMENT  OF  FRACTURES 

Krause,  Deutsche  medicinische  Wochenschrift,  1891,  No.  13. 

Korsch,  Berliner  klinische  Wochenschrift,  No.  2. 

Bruns,  Beitrage  zur  klinische  Chirurgie,  Band  X,  Heft  II,  18. 

Dollinger,  Centralblatt  fur  Chirurgie,  1893,  No.  46. 

Warbasse,  Transactions  of  the  Brooklyn  Surgical  Society,  October,  1 894. 

Bardeleben,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kon- 

gress,  1894. 
Albers,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kongress, 

1894. 
Krause,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIII.  Kongress, 

1894. 
Pilcher,  Transactions  of  the  American  Surgical  Association,  volume  XIV,  1896. 
Woodbury,  New  York  Medical  Record,  1897. 

Roberts,  Transactions  of  the  American  Surgical  Association,  volume  XIV,  1896. 
Woolsey,  New  York  Medical  Record,  1897. 
Cabot,  New  York  Medical  Record,  1897. 
Bradford,  New  York  Medical  Record,  1897. 

THE  EPIPHYSES 
Quain,  Dwight,  Gray,  Morris. 

Poland,  John,  F.R.C.S.,  Traumatic  Separations  of  the  Epiphyses,  1898. 
Brunne,   Das  Verhaltniss  die  Gelenkkapselen  zu  die  Epiphyse  die    Extremitiiten- 
Knochen. 

MASSAGE 

Bennett,  W.  H.,  London  Lancet,  June  2,  1900 ;   London  Lancet,  Feb.  5,  1898. 


NDEX 


Ambulatory      treatment      of 
fractures,  440 

Conclusions    as    to    ambulatory    treat- 
ment, 446 
Plaster  splint,  442 


Bibliography,  449 
Bones  of  the  foot,  396 

Astragalus,  396 

Hot-air  baking,  400 

Massage,  400 

Metatarsal  bones,  401 

Open    fracture    of    astragalus    and    os 

calcis,  401 
Os  calcis,  397 
Phalanges,  402 
Treatment,  399 


Carpus,      metacarpus,      pha= 
langes,  242 
Carpus,  242 

Treatment,  243 
Metacarpal  bones,  245 

Method  of  reduction,  245 
Symptoms,  245 
Treatment,  246 

By  pads,  248 

Massage.  251 

Pads  and  extension,  249 

Use  of  roller  bandage,  249 
Clavicle,  106 

Anatomy,  106 
In  childhood,  109 
Operative  treatment,  116 
Prognosis,  116 
Symptoms,  107 
Treatment,  109 

In  adults,  109 

In  children,  1 13 

Modified  Sayre  dressing,  112 

Recumbent  posture,  109 

Clinical  cases,  3S 

Injury  to  the  head,  38 

Colles'  fracture,  219 

Anatomy,  218 


Associated  lesions,  231 

Care  of  splint,  237 

Contusion  of  bones  near  the  wrist,  228 

Differential  diagnosis,  227 

Dislocation  of  the  wrist  backward,  228 

Examination,  220 

Fracture  of  forearm  near  wrist,  229 

Massage,  238 

Method  of  reduction,  232 

Prognosis,  240 

Result,  240 

Retentive  apparatus,  235 

Reversed  Colles'  fracture,  240 

Separation  of  lower    radial  epiphysis, 

229 
Sprain  of  the  wrist,  227 
Symptoms,  222 
Treatment,  232 


Elbow    (lower    end    of  the    hu- 
merus), 155 
After-care  of  elbow  injuries,  183 
Differential  diagnosis  of  elbow-region 

lesions,  164 
Dislocation  of  the  radius  and  ulna 

backward,  164 
Fracture  of  the  external  condyle,  168 
Fracture  of  the   head   and  neck  of 

the  radius,  166 
Fracture  of  the  internal  condyle,  167 
Fracture  of  the  internal  epicondyle, 

167 
Fracture  of  the  olecranon  process  ot 

ulna,  166 
Separation  of  the  lower  epiphysis  of 

the  humerus,  175 
Subluxation  of  the  head  of  the  ra- 
dius, 164 
T-fracture  into  elbow-joint,  175 
Transverse  fracture   of  shaft  of  the 

humerus,  168 
Method  of  examination,   157 
Carrying  angle,  159 
Head  of  the  radius,  159 
Measurements,   160 
Movements  at  elbow-joint,  159 
Three  bony  points,  157 
Possible  lesions  of  elbow  region,  163 


453 


454 


INDEX 


Prognosis,  185 

Summary  of  examination  of  elbow,  161 

Treatment,  176 

Acutely  flexed  position,  177 
Epiphyses,  403 

Acromion  process  of  scapula,  408 
Dates  of  ossification,  404 
Lower  epiphysis  of  the  femur,  405 
Lower  epiphysis  of  the  humerus,  407 
Lower  epiphysis  of  the  radius,  406 
Lower  epiphysis  of  the  tibia,  40S 
Order  of  frequency  of  separation,  404 
Upper  epiphysis  of  the  humerus,  405 
Upper  epiphysis  of  the  tibia,  408 


Fat  embolism,  318 
Femur,  256 

Ambulatory    treatment,     fracture      of 

femur,  299 
Anatomy,  256 
Expectant  treatment,  296 
Massage,  298 
Prognosis,  300 
Result  to  be  satisfactory,  300 
Results,  301 
In  childhood,  305 
Treatment,  305 

Bradford  frame,  308 
Bradford  frame,  construction,  309 
Buck's  extension,  305 
Cabot  posterior  wire  splint,  305 
Plaster-of- Paris.  305 
Lower  epiphysis  of,  309 
Separation,  309 
Anatomy,  309 
Diagnosis,  313 
Prognosis,  314 
Treatment,  314 

After-treatment,  316 
Massage,  317 
Operative  reduction,  315 
Reduction  by  manipulation,  315 

Neck  of,  in  adults,  256 

Bryant's  triangle,  261 

Examination,  259 

Measurement,  260 

Prognosis.  264 

Results,  264 

Symptoms,  257 

Treatment,  265 

After-care  of  traction  method,  268 
Construction     of    Thomas'     hip- 

splint,  269 
Fixation  method,  268 
Genera]  considerations,  265 
I  .ateral  pressure,  273 
Simple  tra<  lion  method,  267 
'I  he  lied,  267 
Thomas'  hip-splint,  269 


Thomas'     hip-splint,    application 

of,  271 
Thomas'    hip-splint,  summary    of 
construction,  270 
Neck  of,  in  children,  274 

Treatment,  276 
Shaft  of,  in  adults,  278 

Backward  bending  of  injured  thigh, 

294 
Buck's  extension,  285 
Measurements,  278 
Method  of  examination,  284 
Objects  of  treatment,  282 
Outward  bowing  of  injured    thigh, 

293 
Rotation  outward  of  injured  thigh, 

293 

Shortening  of  injured  thigh,  293 

Symptoms,  278 

Transportation  of  patient,  279 

Treatment,  279 
Subtrochanteric  fracture,  295 

Expectant  treatment,  295 

Operative  treatment,  296 
Supracondyloid  fracture,  296 

After-treatment,  297 

Tenotomy,  296 

Forearm,  187 

Coronoid  process  of  the  ulna,  193 

Greenstick  fracture,  187 

Head  and  neck  of  radius,  189 

Radius  and  ulna,  187 

Separation   of  the   lower   epiphysis  of 

radius,  191 
Shaft  of  the  radius,  190 
Shaft  of  the  ulna,  193 
Symptoms.  187 
Treatment,  194 

After-care  of  the  plaster  splint,  198 
After-care  of  wooden  splint,  203 
Application  of  the  wooden    splint, 

201 
Fracture  of  both   radius  and 

ulna,  194 
Fracture  of  neck  of    radius, 

and  coronoid  of  ulna,  204 
Fracture  of  shaft  of  radius,  204 
Fracture  of  shaft  of  ulna,  204 
Greenstick  fracture  of  bones 

of  forearm,  209 
Length  of  time  splints  remain  on,  205 
Massage,  205 
Palmar  and  dorsal  wooden   splints, 

200 
Precaution   in  using  plaster-of- Paris 

splint,  197 
Prognosis,  206 
Result  of  treatment,  206 
Separation    of    lower    radial 
epiphysis,  204 


INDEX 


455 


Hemorrhagic  internal  pachy= 

meningitis,  30 
Humerus,  121 

Anatomy,  121 

Lower    end   of   humerus.       See 

Elbow. 
Malignant    disease    at    seat   of 

fracture,  155 
Musculospiral  nerve,  153 

Symptoms  of  involvement,  154 
Treatment  of  the  lesion,  154 
Shaft  of  the  humerus,  144 

New-born  fractures,  153 

Prognosis,  153 

Spiral  fracture  of  humerus,  144 

Symptoms,  144 

Treatment,  146 

Little  or  no  displacement,  146 
Considerable  displacement,  151 
Upper  end  of  the  humerus,  122 

After-care.  140 

After-treatment  of  operated  cases  of 
dislocation  of  upper  fragment,  143 

Diagnosis,  126 

Dislocation  of  humeral  head,  127 

Dislocation  of  upper  fragment  com- 
plicating fracture,  142 

Examination  of  shoulder,  122 

Fracture  of  anatomical  neck,  128 

Fracture  of  surgical  neck,  136 

Oblique    fracture  of  surgical    neck, 
142 

Prognosis,  140 

Result,  140 

Separation  of  the  upper  epiphysis, 
128 

Treatment,  137 

Fractures  of  anatomical  and  sur- 
gical necks,  137 
Separation  of  the  upper  humeral 
epiphysis,  137 


Inferior  maxilla,  58 

Examination,   59 
Symptoms,  59 
Treatment,  61 

Body  and  ramus,  61 

Body  and  ramus  upon  the  same  or 
opposite  sides,  70 

Coronoid  and  articular  processes,  71 

Making  of  dental  splint,  66 

Ramus  of  maxilla,  68 


Leg,  341 

Anatomy,  341 

Examination  of  fractured  leg,  346 
General  observations,  345 
Symptoms,  34S 


Treatment,  351 

Care  of  the  heel,  361 

Care  after  permanent  dressing  is  ap- 
plied, 372 

Fractures  difficult  to  hold  re= 
duced,  365 

Plaster- of- Paris  splint,  368 
Operative  methods,  368 

Fractures  with  considerable 
immediate  swelling,  354 

Fractures  with  little  displace= 
ment  or  swelling,  351 

Massage,  374 

Open  fractures,  369 

Permanent  dressing,  370 
Wound  of  the  soft  parts,  370 

Padding  of  the  posterior  wire  splint, 
362 

Permanent  dressing,  359 

Pillow  and  side  splints,  357 

Plaster-of- Paris,  359 

Posterior  wire  and  side  splints,  359 

Posterior    wire    splint,    method    of 
making,  360 

Prognosis,  376 

Refracture  of  bones  of  the  leg,  378 

Results  after  fracture  of  the  leg,  377 

Temporary  dressing,  357 
Thrombosis  and  embolism,  378 

Malar,  52 

Examination,  52 
Palpation  of,  52 
Symptoms,  53 
Treatment,  54 

Nonoperative,  54 

Operative,  55 

Malignant  edema,  317 
Materials  needed  for  care  of 

closed  fractures,  447 
Medicolegal  relations  of  Rdnt= 

gen  ray,  423 

Nasal  bone,  44 

Anatomy,  44 
Complications,  46 
Nasal  septum,  47 
Prognosis,  51 
Symptoms,  46 
Treatment,  49 

Adhesive  plaster,  50 

Asch's  tube,  49 

Cleansing  nasal  cavity,  50 

Cobb's  splint,  50 

Coolidge's  splint,  50 

Hematoma  of  septum,  51 

Roe's  elevator,  49 

Tin  splint,  50 


456 


INDEX 


Nonunion  of  fractures,  207 


Olecranon,  210 

After-care,  216 
Operative  treatment,  215 
Summary  of  treatment,  218 
Symptoms,  210 
Treatment,  nonoperative,  213 


Patella,  319 

Anatomy,  319 
After-treatment,  331 
Causes  of  fracture,  323 
Maintenance  of  reduction,  329 
Massage,  326 
Open  fracture,  333 

Operative  treatment  in   recent 
closed  fractures,  337 

Limitations  of,  339 

Method  of,  340 

Restoration  of  function,  340 
Plaster-of- Paris  splint,  330 
Prognosis,  334 

Reduction  of  the  fragments,  327 
Removable  splint,  330 
Restoration  of  the  function  of  the  joint, 

332 
Results,  336 
Symptoms,  323 
Treatment,  324 

Indications,  324 

Limitation  of  the  effusion,  324 
Treatment,     summary     of     expectant 

methods,  333 

Pelvis,  99 

Examination,  99 
Ilium,  99 
Prognosis,  105 
Pubis,  101 

Rupture  of  bladder,  104 
Rupture  of  urethra,  103 
Treatment,  10 1 
Visceral  lesions,  102 

Phalanges,  251 

Open  fracture  of  phalanges,  254 
Symptoms,  253 
Treatment,  253 

Copper  wire,  254 

Letter  paper,  254 

Splint  wood,  254 

Tin  splint,  254 

Plaster=of=Paris,  425 

Application     of    the     plaster-of-Paris 

splint,  431 
I  textrin  bandage,  439 

Removal  of  the  plaster  splint,  438 
Rolling  the  plaster,  425 


Pott's  fracture,  379 

Anatomy,  379 

Care  after  permanent  dressing,  392 

Dupuytren  splint,  386 

Massage,  393 

Open  Pott's  fracture,  394 

Operative  treatment  of  old  Pott's  frac- 
ture, 394 

Plaster-of-Paris  splints,  390 

Prognosis,  394 

Posterior  wire  splint  with  curved  foot- 
piece,  389 

Results,  394 

Stimson's  splint,  390 

Symptoms,  381 

Treatment,  382 


Ribs,  91 

After-care,  95 
Anatomy,  91 
Complications,  92 
Operative  treatment,  95 
Symptoms,  91 
Treatment,  expectant,  92 

Rontgen  ray,  409 


Scapula,  118 

Acromial  process,  1 18 
Body  of,  118 
Neck  of,  118 
Treatment.  1 19 

Septicemia,  317 
Skull,  17 

Concussion  and  contusion  of  the  brain, 

17 
Compression  of  the  brain,  18 
Diagnosis,  32 

Examination  of  the  patient,  31 
Extradural  hemorrhage,  19 
Fractures  of  the  base,  24 
Fractures  of  the  vault,  22 
( Jeneral  observations,  32 
Interval  of  consciousness,  19 
Laceration  of  the  brain,  1 8 
Later  results,  38 
Operative  treatment,  35 
Pistol  shot  wounds,  37 
Prognosis,  37 

Subarachnoid  serous  exudation,  21 
Symptoms  of  fracture  of  the  base,  27 
Treatment,  34 

Ear,  35 

Mouth.  35 

Nose,  35 

Scalp,  35 


INDEX 


457 


Sternum,  96 

Treatment,  97 
Operative,  98 

Position   for  reducing  ordinary  dis- 
placement, 97 

Superior  maxilla,  55 

After-care,  57 
Diagnosis,  55 
Treatment,  56 

Closed  fracture,  56 

Open  fracture,  56 


Tetanus,  219 

Traumatic  gangrene,  317 


Unconsciousness,  causes  of,  29 


Vertebrae,  72 

Anatomy,  72 


Examination  of  injury  to  spine,  75 

General  symptoms  common  to  all  frac- 
tures, 76 

Gunshot  fracture  of,  90 
Treatment,  90 

Lesions  tabulated  by  regions,  75 

Prognosis,  81 

Symptoms  of   injury   to   cervicodorsal 
vertebrae,  79 

Symptoms  of  injury  to  dorsal   verte- 
brae, 78 

Symptoms    of    injury    to    last    dorsal 
vertebra;,  77 

Symptoms    of    injury    to    midcervical 
vertebrae,  80 

Symptoms  of  injury  to  the  first    two 
cervical  vertebrae,  80 

Treatment,  81 
Cystitis,  89 

Operative  interference,  84 
Plaster-of- Paris  jacket,  87 
Signs  of  partial  lesion,  82 
Signs  of  transverse  lesion,  81 
Summary,  89 


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COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
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C2e(ll4l)M100 

RD101 


Scudder 


Scu2 
1901 


COLUMBIA  UNIVERSITY  LIBRARIES  Ihsl.stx) 

RD  101  Scu2  1901  C.1 

The  treatment  of  fractures 


2002129850 


